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1 






ON DISEASES OF THE SKIN. 



PLATES 

TO 

"WILSON ON DISEASES OF THE SKIN.' 



FOE SALE SEPAKATE, 

A SERIES OF PLATES ILLUSTRATING THE PRESENT WORK, 



.' O.N SI STING OF 



TWENTY BEAUTIFULLY EXECUTED PLATES, 

OF WHICH 

THIRTEEN ARE EXQUISITELY COLORED, 

PRESENTING THE NORMAL ANATOMY AND PATHOLOGY OF THE SKIN, AND EMBRACING 
ACCURATE COLORED REPRESENTATIONS OF NEARLY ONE HUNDRED VARIE- 
TIES OF DISEASE, MOST OF THEM THE SIZE OF NATURE. 



Price, hi cloth, $5.50. 



To the series of plates prepared by Mr. Wilson to accompany his 
work on " Diseases of the Skin,'' and which are referred to throughout 
its pages, the publishers have added those prepared by him for his 
volume on " Syphilis and Syphilitic Eruptions." The diseases repre- 
sented in these latter are treated at some length, while they form no 
part of the original plates. It is therefore hoped that, in rendering 
the series of illustrations more complete, the value of the whole has 
been correspondingly increased. 

For beauty of drawing, and accuracy and finish of coloring, these 
plates are confidently presented as superior to anything of the kind as 
yet issued in this country- 



The " Diseases of the Skin,'" by Mr. Krasmus 
Wilson, may now be regarded as the standard work 
in that department Of medical literature. Tin- 
plates by which this edition is accompanied leave 
nothing to be desired, so fur as excellence of de- 
lineation and perfect accuracy of Illustration are 
concerned.— M* dico-Chimrgical Review. 



Of these plates it is impossible to speak too 
highly. The representations of the various forms 
of cutaneous disease are singularly accurate, and 
the coloring exceeds almost anything we have met 
with in point of delicacy and finish. — British and 
Foreign Medical Review. 



N 




^ 



DISEASES OF THE SKIN. 



ERASMUS WILSON, F. E. S. 



SIXTH AMERICAN 

FROM THE 

FIFTH AND REVISED LONDON EDITION. 



WITH ILLUSTEATIONS ON WOOD. 




PHILADELPHIA: 

LEA AND BLAN CHARD. 

18 65. 



V > ^ 









PHILADELPHIA: 

HERMAN & CO., PRINTERS. 



i-/' 






PREFACE, 



Cutaneous Medicine is an important branch of General Medi- 
cine ; it embraces every form of pathological change which takes 
place in the external surface-tissues of the body. It demands, for 
its wiorough comprehension, all that appertains to the philosophy of 
General Medicine, as well as the particular knowledge which belongs 
to the dermal textures. It presents itself to our notice in the double 
sense of a disturbance of the general organism of the body, and as a 
disturbance of the special organism of the skin. In the former 
character it calls upon us to consider the phenomena, as well of the 
organic as of the animal constitution ; in the latter it directs our 
inquiry into the organism of the skin, both in its normal and in its 
pathological condition. In its constitutional character, it includes 
all that concerns the health of the individual ; in its special or local 
character, it comprehends, in an equal degree, all that belongs to 
the organism of the part : its vessels with their blood ; its nerves 
with their governing principle ; its glandular apparatus with their 
secernent functions ; and its various component tissues. 

Just as in General Medicine there exist disorders of the organic 
system, disorders of the blood, disorders of the nervous system, and 
disorders which are not directly traceable to either of these heads ; 
so, in Cutaneous Medicine, there are disorders with which the 
glandular system is chiefly concerned; others in which the main 
cause of evil is the blood ; others which are chiefly referable to the 
nerves; and others which do not exclusively appertain to any one 
of these sources. And, for the same reason, that, to be clearly un- 
derstood, the morbid phenomena of General Medicine require to 
be classified according to some recognized principle ; so, also, do 
the morbid manifestations included by Cutaneous Medicine. 

Classification would seem to have been coeval in its origin with 
the earliest observation of diseases of the skin. Hippocrates laid 
the foundation of an Etiological Classification, and the basis of a 

2 



VI PREFACE. 

sound practice, as true at the present day as it was in his own times, 
when he divided cutaneous diseases into local and constitutional. 
Local affections he believed to depend upon some pathological 
change present in the part, and independent of the general consti- 
tution ; and constitutional affections he regarded as an effort on the 
part of nature, to throw out or eliminate a cause of disease by the 
cutaneous tissues. Lorry adopted the classification of Hippocrates 
and gave it additional expansion ; and the work of Baumes, enti- 
tled, "iNouvelle Dermatologie," is founded on a similar hypothesis. 

Galen, following the medical theory of his day, became the 
founder of a Topographical Classification, when he divided cu- 
taneous diseases into such as affect the head ; and such as affect the 
remainder of the body. And this classification has been followed 
by Jerome Mercurialis, a physician of Italy, who flourished in 
the sixteenth century ; by Daniel Turner, in England, in 1714 ; 
and by Alibert, in his first classification, in France. 

Riolanus, a French physician, who was at the height of his repu- 
tation during the latter half of the sixteenth century, tells us that 
some physicians include all diseases of the skin under three genera, 
namely, alterations of smoothness, of color, and of magnitude ; but 
that, as this arrangement affords no place for disorders of the hair, 
others prefer to distinguish them under the three heads of Pustules, 
Deformities, and Tubercles: Pustules comprehending all eruptions 
attended with roughness of the skin, whether pimples, vesicles, 
true pustules, or scales ; Deformities, marks of all kinds, morbid 
coloration, and diseases of the hair ; and, Tubercles, warts and 
condylomata. Plenck, in 1776, amplified this simple grouping 
into fourteen classes ; namely, Maculae, Pustulae, Vesiculae, Bullae, 
Papulae, Crustae, Squamae, Callositates, Excrescentiae, Ulcera, Vul- 
nera, Insecta, Morbi unguium, and Morbi pilorum ; and these four- 
teen classes he subdivided into one hundred and fifteen genera. 

This classification, which treats the visible phenomena of cuta- 
neous disease as Linnaeus treated the plants and efflorescence ot 
the vegetable world, is essentially artificial, and, like the botanical 
arrangement of Linnaeus, may be styled the Artificial Classifi- 
cation — in other words, the classification of signs or appearances. 
Pruned of some of its members, the classification of Plenck was 
adopted by Willan, and became the basis of the classification 
published by him in 1778. The orders of cutaneous diseases of 
Willan, eight in number, are as follows : Papulae, Squamae, Exan- 
themata, Bullae, Vesicuke, Pustulae, Tubercula, Maculae. 

Alibert, in framing his first classification, adopted the topo- 
graphical basis founded by Galen ; but, subsequently, proposed a 



P KEF ACE. Vll 

scheme of arrangement which he designated the " Natural Sys- 
tem." This system embraced the whole of diseases of the skin 
under the general title of "Dermatoses." The dermatoses were 
divided into twelve groups, the twelve limbs of the " Arbre des 
Dermatoses;" and the twelve limbs gave off numerous branches 
which represented the genera of his classification. Alibert's na- 
tural system was arranged as follows : 

Dermatoses Eezemateuses. — Erythema ; erysipelas ; pemphix ; zos- 
ter ; phlyzacia ; cnidosis ; x epinyctide ; 2 olophlyctide ; 3 ophlyc- 
tide ; 4 pyrophlyctide ; 5 anthrax ; furunculus. 

Dermatoses Exanthemateuses. — Variola ; vaccinia ; clavele'e ; 6 vari- 
cella ; nirle f roseola ; rubeola ; scarlatina ; miliaria. 

Dermatoses Teigneuses. — Achor ; 8 porrigo ; favus ; trichoma. 9 

Dermatoses Dartreuses. — Herpes; 10 varus; 11 melitagra ; 12 esthio- 
mene. 13 

Dermatoses Cancereuses. — Carcinoma ; keloide. 

Dermatoses Lepreuses.—-'Lexice ; u spiloplaxie ; 15 elephantiasis ; rade- 
sige. 16 

Dermatoses Veroleuses. — Syphilis ; mycosis. 17 

Dermatoses Strumeuses. — Scrofula ; farcinoma. 

Dermatoses Scahieuses. — Scabies ; prurigo. 

Dermatoses Hemateuses. — Peliosis ; 18 petechia. 

Dermatoses Dysehromateuses. — Pannus ; 19 achrome. 20 

Dermatoses Seteromorphes. — Ichthyosis ; tylosis ; verruca ; onygos ; 21 
dermatolysie ; 22 nsevus. 

Twenty years ago, when the first edition of this work was pub- 
lished, 23 I constructed a classification founded on the anatomy and 



1 Urticaria. 

2 A nocturnal eruption, disappearing by day, described only by Alibert. 

3 Herpes. 4 Aphthae. 5 Malignant pustule. 
6 A varioloid of sheep transmissible to man. 7 A varioloid. 

8 Crusta Lactea. 9 Plica polonica. 

10 The squamous diseases, Lepra, including Psoriasis and Pityriasis. 

11 Acne and Sycosis. 12 Impetigo. " Lupus. 

14 The Jewish leprosy. 1S Malum mortuum. 

16 The name given to an elephantiasis (?) of northern countries, in Norway. 

17 This genus includes Frambcesia and Molluscum. 18 Purpura. 

19 This genus includes Lentigo, Ephelis, Pityriasis versicolor and Pityriasis nigra. 

20 Vitiligo; Albinismus. 

21 Onychia. . 82 Abnormal extensibility of the skin. 

23 The dates of the several editions of this work are: 1842; 1847; 1851; 1857; 
1863. 



Vlll PREFACE. 

physiology of the skin, a Physiological Classification ; and I 
took as the heads of my arrangement the natural division of the 
skin into — 1. Derma proper; 2. Sudoriparous system; 3. Sebi- 
parous system ; 4. Hair and hair-follicles. The first of these heads 
I subdivided into five secondary groups, as follows: Inflammation ; 
Hypertrophy of papilla? ; Disorders of the Vascular tissue ; Disor- 
ders of sensibility; and Disorders of chromatogenous function. 
And the first of the secondary groups, namely, inflammation, I 
further divided into : Congestive inflammation ; Effusive inflam- 
mation ; Suppurative inflammation ; Depositive inflammation ; 
Squamous inflammation ; and inflammation from the presence of 
Acari. 

Time, however, brought with it the conviction, that however 
well adapted such a classification as the Physiological Classification 
might be for the student, or for the mere scientific inquirer, it was 
not equally suitable to the practitioner; and, that, as the primary 
object of the study of medicine should be to cure disease ; a 
classification must be sought for that would carry with it the idea 
and principle upon which our curative operations ought to be con- 
ducted. These were the views with which I advanced the classifi- 
cation adopted in the fourth edition of this work ; a classification 
founded upon the supposed cause of Cutaneous disease ; and which 
I then distinguished as an Etiological Classification. Further 
experience has confirmed my approval of the etiological classifica- 
tions, so that, although I foresee a probability of improving it at 
some future period, that time has not yet arrived ; and I am con- 
tent for the present to follow it without alteration. 

As the cause of disease is naturally obscure, our appreciation of 
the nature of a cause must be greatly influenced by the theory of 
medicine, which has been impressed upon us in our early educa- 
tion, or by the prevalent theory of the day. One theory that has 
been handed down to us from a very early age, is that of the hu- 
mors ; which assumes that the majority of diseases originate in a 
m6rbid condition of the humors of the body, and especially of the 
blood. This is the foundation of the Humoral Pathology, and the 
disciples of this doctrine are the Humoralists. Humoralism was 
early adopted as an explanation of cutaneous disease; and the 
practice which has been founded upon that theory has been most 
successful in the treatment of these diseases. Theory assumes a 
morbid alteration of the blood ; practice exerts all its powers to 
remove the offending constituents of the blood, to improve the 
condition of the blood ; in fact, to purify the blood. 

But Humoralism does not explain all the known phenomena of 



PREFACE. IX 

cutaneous disease ; and for the simple reason that Humoralism 
addresses itself only to the fluids of the body ; and although it 
must be admitted that there can be no healthy solids without 
healthy fluids, yet, on the other hand, the nervous system plays so 
important a part in the health of the body, and in the health of the 
blood itself, that we are bound to recognize certain phenomena 
manifested by diseases of the skin as originating in the nervous 
system ; as being, in fact, neuropathic phenomena. In the treat- 
ment of diseases of the skin, we must therefore chasten our hu- 
moral views, with views drawn from a neurotic source, with dyna- 
mic views ; and while we bestow our chief attention on the purifi- 
cation of the blood, we must at the same time comprehend the 
importance and secure the integrity of that governing influence, 
the nervous power. 

Reviewing the long list of cutaneous diseases, we might select a 
group which originate in the presence of a poison in the blood, 
which, in a pathological point of view, may be regarded as an 
effort of nature to eliminate a poison which has been accidentally 
admitted into the blood, and which is in its nature foreign to the 
blood. Such is the group of exanthematic fevers, " diseases arising 
from animal poisons of unknown origin, and giving rise to eruptive 
fevers ;" and " diseases arising from the syphilitic poison." But even 
in these diseases we have to regard not merely the action of the 
poison on the blood, but also its influence on the nervous system. 
Irrespective of the neuropathic symptoms which accompany these 
disorders, and follow in their train as sequelse, the occasional para- 
lysis, partial or complete, we not unfrequently hear of cases of 
" nervous small-pox," and we recognize the intense neuralgia of 
syphilis. We have, therefore, in the treatment of these diseases, 
to balance our humoral views with a remembrance of the necessity 
of keeping up the tone and power of the system, — we must act the 
part of dynamo-humoralists. 

In another and very important, because the most common of the 
diseases of the skin, namely, the eczematous group, we have also 
an impure state of the blood, but an impurity different from that 
of the preceding, not a poison foreign to the blood, but an impurity 
depending on mal-assimilation, crude and morbidly altered organic 
elements and effete material, which has failed to be eliminated by 
the proper emunctory organs. This accumulation not unfrequently 
results from a preceding deficiency of power of the nervous system ; 
or acting upon individual nerves, may give rise to a morbid altera- 
tion in the tissues which those nerves supply, constituting an appa- 
rently local eczema. Here, again, we see the necessity of combin- 



X PREFACE. 

ingthe neuropathist and the humoropathist in administering to the 
one harmonious whole, which nature had in view in the construc- 
tion of the animal frame. "Weak nerves may be the occasion of 
morbid blood, morbid blood may react on the weakened nerves, or 
if the morbid blood precede the weak nerves, then the neuropathic 
phenomena will be secondary. As in the preceding group of dis- 
eases, the principle of treatment must be humoralist, so far as the 
correction of the impurity of the blood, dynamic, to support the 
tone of and invigorate the nervous system. 

In another group of cutaneous diseases, the affection of the nerve 
obviously precedes the cutaneous disorder ; and there exists no 
ground for suspecting a faulty constitution of the blood ; — for ex- 
ample, Herpes ; a draught of cold air chills a cutaneous nerve ; the 
tissues to which the filaments of that nerve are distributed are low- 
ered in tone ; circulation is disturbed, retarded, congestion and vesi- 
cation follow. In Herpes Zoster, we see the curious and striking 
phenomenon of the affection of the cutaneous branches of a single 
intercostal nerve. Here the healthy blood must be assumed to be 
the irritant, acting on tissues depressed in their vitality by the pre- 
vious injury done to the nerve by the simple operation of cold. 
Commonly the nerves which govern the circulation and nutrition 
of the part chiefly suffer ; but sometimes the sensitive filaments are 
also affected, and then we may have neuralgia in every degree, from 
simple tingling, smarting, and pricking, to intense and deep-seated 
pains, which are obviously referable to the trunk of the nerve. In 
cases such as these, we cease to be humoralists, unless we can find 
some error of digestion or assimilation also present ; we are for the 
time being Dynamists. But the respective attributes of humoralism 
and solidism are too precious to permit us to part willingly with 
either ; we will be "big of heart" and hold both. 

In the influence of Cold and Heat upon the skin we have striking 
examples of the Neuropathic Theory. Let us take the everyday 
example of a common chilblain. A healthy child is exposed to the 
cold ; the cold seizes chiefly on the peripheral parts of the body, 
because in them the nervous filaments are the least protected ; the 
part is benumbed, the tissues are lowered in their tone, their 
vitality is reduced ; circulation returns, the vessels, having lost 
their contractility, no longer carry the blood as actively as usual 
through the weakened tissues ; the blood accumulates, this is con- 
gestion ; inflammation follows, and with inflammation its conse- 
quences. This is clearly an example of pure blood acting as an 
irritant upon the tissues of the skin, in consequence of their depri- 
vation of nervous power. 



PREFACE. XI 

It would be easy to accumulate examples in which the nerves, 
governing the circulation, the nutrition, the tone, and the sensation 
of the skin, are weakened and injured by disease ; but I will satisfy 
myself with one further example, namely, alopecia areata. On a 
circular plot of skin of the scalp, probably in close relation with a 
branch of a cranial nerve, the hair has fallen off, the part is bare, 
it is thin, it is pale, it is lowered in sensibility. There can be no 
doubt as to the pathological condition of this portion of skin. We 
can see it, we can touch it ; we can bring our best organs of sense 
and judgment to bear upon it. Its nutritive power is exhausted, 
for it is thin, and it is no longer capable of performing its normal 
function of producing hair ; its circulation is diminished, for it is 
pale and ansemic ; its sensitive nerves must be more or less para- 
lyzed, for its sensibility is to a considerable extent lost. Here, 
again, is a case in which our dynamic influence must be brought 
to bear upon our patient. We must improve nutrition, we must 
improve innervation, both generally and locally. 

That same great mind that taught us the importance of recog- 
nizing the constitutional origin of local disease, also impressed upon 
us the delicate handling of the local disorder, whether proceeding 
from a constitutional or from a local cause. That certain diseases 
obviously proceed from a local cause, and are in their essence local 
diseases, and independent of constitutional influence, is the natural 
inference to be drawn from the foregoing prolegomena. This 
truth has been strongly impressed upon us by the celebrated der- 
matologist of Vienna, Hebra. Many cutaneous diseases which in 
this country, and with our humoral tendencies, we should be led 
to treat by constitutional as well as by local means, Professor Hebra 
would treat by local means alone, and the great success of his treat- 
ment leads us to inquire at what point between the two extremes 
the truth lies concealed. I believe that our lesson will be best 
learned by devoting more attention than heretofore to local treat- 
ment ; and not less to constitutional treatment. The great excel- 
lence of the treatment of disease in England depends upon the pro- 
per appreciation of its almost universal constitutional origin. During 
his late stay in London, Professor Hebra honored me with his pre- 
sence in my consulting-room on several occasions, and has left on 
my mind an ineffaceable impression of his rapid and sound diagnosis, 
and his extraordinary tact in the local management of cutaneous 
diseases. lie is too sound a physician to reject constitutional 
means ; but he declares that they are much less needful than is be- 
lieved by us, and that a very considerable number of diseases are 
local in their nature, and may be perfectly cured by local remedies. 



Xll PREFACE. 

The name of Hebra leads me to another topic. Those who have 
honored me by perusing my writings and following my inquiries, 
may have noted the difficulty which I have experienced in dealing 
with the word "psoriasis." By my immediate predecessors, and 
especially by the French, I found the words psoriasis and lepra 
used synonymously, both being applied to one and the same dis- 
ease. Again, it was not unfrequent, as in the writings of Bateman, 
to see the term psoriasis, besides being used synonymously with 
lepra, also applied to eczema in its most chronic period, when it is 
accompanied with considerable thickening and extensive desqua- 
mation of the diseased patch. Hence, to clear away the confusion 
occasioned by the misuse of this term, I recommended its abolition, 
or, at the least, its application solely to the chronic eczema above 
noted. But it may very properly be asked, Why call eczema by 
any other name than its own ? I can only answer, that I have 
done so heretofore in deference to authority, and to a widely- 
spread custom. Perhaps the moment has come, and I hope it has, 
when a better, and possibly the proper use of the term, may be 
recognized. 

To return to Hebra. The term Lepra — der Aussatz in German 
— signifies the eruption, the great eruption. It is synonymous 
with Leprosy, the leprosy, the ancient leprosy, that which has 
since been called elephantiasis. Therefore, let us bestow the term 
lepra where it rightfully belongs, or reject it altogether. The tri- 
vial affection which we at present call lepra has no single point of 
comparison with leprosy. "We cannot but admit the truth of this 
argument, and we cannot, also, but recognize in an instant the 
monstrous absurdity of calling a comparatively insignificant dis- 
ease by so portentous a name. Let us suppose a patient address- 
ing his medical adviser : " What is the name of my complaint, 
Doctor?" And now I will ask any medical man to whom this 
question has ever been addressed, to reflect on the pang which has 
gone through his entire frame before he has brought himself to 
give the only possible answer — " Lepra." " What !" exclaims the 
startled patient, "Leprosy?" And then the apologetic response — 
"No, not leprosy; lepra." And the medical man can only hope 
that the patient will not go at once to his dictionary, and find out 
that either the dictionary is wrong or the Doctor. 

Now, Hebra cuts the Gordian knot. Eczema he calls eczema; 
Lepra, lepra; and that very common affection which we at present 
term lepra, he calls psoriasis. The change is simple, the reasons 
for it important. We cannot do better than adopt it. Moreover, 



PREFACE. Xlll 

it suits the spirit of the British bull-dog to call things by their pro- 
per names, and we are too noble in our nature not to recognize 
and value the intellect of our foreign brethren. The great Inter- 
national Exhibition of 1862 will not have existed in vain, if it have 
accomplished no more than to enable us to give the proper name 
to a very common and troublesome disease. 

In the present edition the reader will find numerous emenda- 
tions and additions, both in pictorial and typographic illustration. 



London, November, 1862. 



CONTENTS. 



CHAPTEE I. 



Anatomy and Physiology of the Skin 



ITOMI AJNJJ JTMIS1ULUUI V£ TU.& OJi.lJN , 

Pigment of the skin, .... 






47 


Sudoriparous system, .... 






49 


Sebiparous system, 

Hairs, ...... 






52 
54 


Nails, 






68 


Physiology of the skin, .... 






72 



CHAPTEE II. 

Classification of Diseases of the Skin, 
Tables of Classification, 



DO 



CHAPTEE III. 

General Pathology of the Skin, 



91 



CHAPTEE IV. 

General Therapeutics of the Skin, 



97 



CHAPTEE V. 

Erythematous or Exanthematous Eruptions, 
Erythema, ..... 
Erysipelas, ..... 
Eoseola, ..... 
Urticaria, ..... 



116 
117 
131 
144 
153 



CHAPTEE VI. 



Lichenous or Papulous Eruptions, 
Lichen, .... 
Strophulus, 
Prurigo, .... 



161 
163 
174 
177 



XVI 



CONTENTS. 



CHAPTEE VII. 



EcZEMATOUS OR VESICULAR ERUPTIONS, 

Eczema, .... 
Sudainina, .... 



PAGE 

182 
184 
208 



CHAPTEE VIII. 



Impetiginous or Pustular Eruptions, 
Impetigo, .... 
Ecthyma, .... 



210 
212 
220 



CHAPTEE IX. 



Herpetic and Bullous Eruptions, 
Herpes, . 
Pemphigus, 



223 
224 
235 



PURUNCULAR ERUPTIONS, 

Furunculus, 
Hordeolum, : 

Anthrax, 



CHAPTEE X. 



243 
245 
247 

247 



Scorbutic Eruption, . 
Purpura, . 



CHAPTEE XI. 



254 
255 



CHAPTEE XII. 



Diseases arising from Special External Causes, 
Scabies, 
Malis, 

Ambustio, . 
Gelatio, 



262 
263 
274 
285 
295 



CHAPTEE XIII. 



Diseases arising from Special Internal Causes, 
Lepra, 
Lupus, 

Scrofuloderma, 
Kelis, 
Elephantiasis, 



298 
300 
315 
322 
3L>4 



CONTENTS. 



CHAPTER XIV. 



Diseases arising from the Syphilitic Poison, 



Table of Syphilodermata, . 
Syphiloderruata primitiva, 

(First period) 
Sypliiloderma erythematosum, 
Syphiloderma papillosum, 
Syphiloderma tuberculosum 
Sypliiloderma pustulosum, 
Syphiloderma pilare, . 
Syphiloderma ungueale, 

(Second period) 
Syphiloderma erythematosum 
Syphiloderma tuberculosum, 
Syphiloderma ulcerans, 
Syphilodermata hereditaria, 

(First period) 
Syphiloderma erythematosum 

(Second period ) 
Syphiloderma tuberculosum, 

(Third period) 
Syphiloderma ; lepra, 



PAGE 

382 



390 
399 
403 
403 
404 
405 
407 
410 
411 

412 

413 

417 



CHAPTER XV. 

Diseases arising from Animal Poisons of unknown Origin, and 
giving rise to Eruptive Fevers, 
Rubeola, 
Scarlatina, . 
Variola, 
Varicella, . 
Vaccinia, . 



428 
432 
441 
459 

478 
484 



CHAPTER XVI. 

Diseases affecting the Special Structure of the Skin. 



Diseases of the Vascular Structure, 
Hypertrophia vcnarum, . 
NaM vasculosi, 



508 
508 
510 



CHAPTER XVII. 

Diseases affecting the Special Structure of the Skin. 

Diseases of the Nervous Structure, .... 

Hyperesthesia, ....... 

Anesthesia, ....... 

Pruritus, ........ 



513 
513 
513 
514 



XV111 CONTENTS. 

CHAPTEE XVIII. 

Diseases affecting the Special Structure of the Skin. page 

Diseases of the Papillary Structure, ...... 517 

Verruca, ......... 518 

Clavus, Tylosis, ........ 521 

Pachulosis, ........ 525 



CHAPTEE XIX. 

Diseases affecting the Special Structure of the Skin. 

Diseases of the Pigmentary Structure, 
Melanopathia, 



Spilus vel Naevus P: 
Leucopathia, 
Alphosis, 
Ephelis, 
Lentigo, 
Chloasma, . 
Melasma, . 
Decoloratio argentea 



mentosus, 



525 
526 
534 
535 
535 
537 
538 
538 
540 
541 



CHAPTEE XX. 

Diseases affecting the Special Structure of the Skin. 



Diseases of the Sudoriparous Organs, . 


542 


Idrosis, ...... 


542 


Anidrosis, ...... 


548 


Osmidrosis, ..... 


548 


Cliromidrosis, ..... 


550 


Haemidrosis, ..... 


551 



CHAPTEE XXI. 



Diseases affecting the Special Structure of the Skin. 



Diseases of the Sebiparous Organs, 










553 


Stearrhcea simplex, 










555 


Xeroderma, 














556 


Stearrhcea flavescens, 














561 


Stearrhoea nigricans, 














561 


Ichthyosis schacea, 














563 


Comedones, 














571 


• Accumulationes sebaceae, 














573 


Cornua humana, . 














584 


Tubercula miliaria, 














590 


Tumores serosi, 














591 


Tumores sebacei, . 














591 


Acne, 














593 


Tuberculum malignum, 














597 



CONTENTS. 



CHAPTEE XXII. 



Diseases affecting the Special Structure of the Skin. 



EASES OF THE HAIRS AND HAIR-FOLLICLES, 








599 


Hirsuties, ..... 








600 


Nsevi pilosi, 










601 


Defluvium capillorum, 










604 


Alopecia, .... 










605 


Calvities, .... 










607 


Trichiasis ciliorum, 










611 


Trichiasis coacta, . . 










611 


Trichosis decolor, . 










611 


Trichosis cana, 










613 


Trichosis furfuracea, 










617 


Trichosis plica, 










628 


Erythema folliculorum, . 










630 


Stearrhcea folliculorum, . 










632 


Inflammatio folliculorum, suppurans, 










633 


Sycosis, .... 










634 


Eavus, .... 










637 



CHAPTEE XXIII. 
Diseases affecting the Special Structure of the Skin. 

Diseases of the Nail-Follicles and Nails, 

Degeneratio unguium, ...... 

Onychia. ........ 



653 
655 
656 



CHAPTEE XXIV. 

History and Description of the Itch-animalcule, acarus scabiei, 659 

History and Description of the Steatozoon folliculorum, . . 673 



CHAPTEE XXV. 



Selected Formulae, 
Index, . 



685 



DISEASES OF THE SKIN. 



CHAPTER I. 

ANATOMY AND PHYSIOLOGY OF THE SKIN. 

The skin is the exterior investment of the body, -which it serves to 
cover and protect. It is continuous at the apertures of the internal 
cavities with the lining membrane of those cavities — the internal 
skin, or mucous membrane ; and is composed essentially of two layers, 
the derma and epidermis. 

The derma, cutis, or true skin (Plate II.), is chiefly composed of 
areolo-fibrous tissue ; besides which it has entering into its structure 
elastic tissue and smooth muscular fibre, together with bloodvessels, 
lymphatic vessels, and nerves. The areolo-fibrous tissue exists, in its 
most characteristic form, in the deeper strata of the derma, which 
are consequently dense, white and coarse, while the superficial stra- 
tum is fine in texture, reddish in color, soft, raised into minute papillge, 
and endowed with an abundant supply of vessels and nerves. This 
peculiarity of structure of the derma has given rise to its considera- 
tion as consisting of two layers, the superficial or papillary layer, and 
the deep stratum or corium. 

The epidermis, cuticle, scarfskin, or scurfskin (Plate I.) is a product 
of the derma, which it serves to envelop and defend. That surface 
of the epidermis which is exposed to the influence of the atmosphere 
and exterior sources of injury, is hard and horny in texture ; while 
that which lies in contact with the sensitive papillary layer of the 
derma is soft, and composed of newly-formed cells. Hence this 
membrane, like the derma, offers two strata for our observation, the 
outermost stratum, commonly spoken of as the epidermis, and the 
innermost stratum, or rete mucosum. The latter was considered and 
described by Malpiglii as a distinct membrane, and is frequently 
referred to under the name of rete Malpighianum. 

Besides the derma and epidermis, the skin includes certain import- 
ant secreting organs, and certain appendages, which call for separate 
notice. The secreting organs are the sudoriparous and sebiparous 
glands ; and the appendages, the hairs and the nails. 

The dehma presents considerable variety in degree of thickness in 

3 



34 ANATOMY OF THE SKIN. 

different parts of the body. Upon the more exposed regions, as the 
back, the outer sides of the limbs, and the palms 1 and soles, it is 
remarkable for its thickness ; while on protected parts, as the inner 
sides of the limbs, and the ventral surface of the trunk, it is compara- 
tively thin. On the eyelids, the penis, and the scrotum, again, it is 
peculiarly delicate. The papillary layer also presents differences in 
extent of development ; on the palms of the hands, the pulps of the^ 
fingers, and the soles of the feet, this layer is thick, and the papillae s 
numerous and of great length, while in most other situations it is thin, 
and the papillae are little apparent. Some contrariety is observed, 
besides, in the relative proportion of the layers of the derma ; for on 
the back, where the corium is exceedingly thick, the papillary layer 
is but slightly developed, while on the pulps of the fingers, where the 
latter is strikingly manifest, the corium is thin. 

The areolo-fibrous tissue of the derma is constructed of fibres of 
two kinds, namely, of minute cylindrical fibres, which are identical 
in their nature with the delicate wavy fibres of common areolar or 
cellular substance, and of fibres of elastic tissue, presenting their 
characteristically curved ends, and branching and anastomosing dis- 
tribution. In the superficial strata of the corium, the white fibres are 
collected into small fasciculi, and form an intricate interlacement, 
which supports the papillae, and constitutes a nidus for the capillary 
rete of vessels and terminal plexus of nerves. In the middle strata, 
the fasciculi are larger and flattened, and the areolar network coarse ; 
while in the deep layer (pars reticularis — Plate II., fig. 3) the fasciculi 
are broad — namely, about a line in diameter, and the areolar spaces 
two lines in width. These latter are occupied by small masses of 
adipose tissue, while the fasciculi are continuous with the subcuta- 
neous cellular membrane. The yellow elastic fibres are solitary in 
their arrangement ; they are abundant in the superficial layers of the 
corium, but rare and scantily met with in the deeper strata. The 
areolae left by the interlacement of the fasciculi of the areolo-fibrous 
tissue, are the channels by which branches of vessels and nerves find 
a safe passage to the papillary layer, wherein, and in the superficial 
strata of the corium, they are principally distributed. 

The smooth or unstriped muscular fibre of the derma is distributed 
most abundantly in the deep stratum of the corium, within the spaces 
which give passage to the hair follicles, and especially, in the areola 
of the nipple and in the dartos of the scrotum. These fibres are simple 
homogeneous filaments, smaller than those of muscular fibre of animal 
life ; they are flat and smooth, possess no transverse striae, and have a 
reddish hue. They are fusiform in shape, of variable length, and are 
composed of a thin external membrane, blended with and inclosing a 
soft and finely granular contained substance. The shorter fibres 
have a central nucleus ; the longer ones a succession of nuclei which 
give to the fibre a knotted appearance ; and the nuclei are sometimes 
oval and sometimes elongated or columnar. The fibres are united 
into fasciculi by an adhesive interstitial substance ; and the fasciculi, 

1 In the palm of the hand the derma measured three-fourths of a line in thickness. 



STRUCTURE OF THE DERMA. 35 

which are sometimes round and sometimes flat, are intermingled in 
greater or less proportion with the fasciculi of the areolo-fibrous tissue. 
Kolliker found small bundles of smooth muscular tissue measuring 
T2U t0 7V °f an * ncn * n connection with the hair follicles; these small 
bundles, which have been termed by Eylandt arrectores pilorum, take 
their origin by two or three penicillar digitations (Henle) from the 
upper stratum of the corium nearest the limitary membrane, and 
descend obliquely to the follicle of the hair, to become blended with 
the outermost layer of the ^follicle immediately below the sebiparous 
gland. Kolliker describes two of these muscles as appertaining 
to each hair follicle, but Dr. Lister 1 finds only one, and this on the 
sloping side of the follicle, a position " exactly that which is best 
adapted for erecting, as well as protruding, the hairs." These muscles 
are the- agents of erection of the hairs, and also of that erection of the 
pores of the skin called cutis anserina, or goose-skin; it is not unlikely, 
moreover, that the excretion of the sebiparous glands may be assisted 
by the same agency. It may also be noted that these little muscles 
not only lift up the follicle and give a prominence to the pore, but 
as they take their origin at a short distance from the pore, they at 
the same time depress the surface of the intermediate skin; the term 
spasmus periphericus, has been, not inaptly, therefore, applied to this 
state of the derma. In the areola of the mamma, the bundles of 
smooth muscular tissue have a circular arrangement ; Dr. Lister 
describes them in the deepest part of the corium of the areola mammae 
as a "delicate, pale, reddish yellow fasciculus, circularly arranged." 
Henle thought that he had seen similar muscular tissue in connection 
with the sudoriparous glands of the palm of the hand and sole of the 
foot, but this observation has not yet been verified, and is otherwise 
doubtful. 

The papillary layer of the derma (Plate II., figs. 1, 2) is raised 
into small prominences or prolongations, which are termed papillce ; 
the general form of these papillae is cylindrical and conical, but some 
are club-shaped and slightly flattened, and others spring from a short 
trunk in a tuft of two, to four or five, and are termed "compound," 
the former being "simple" papillae. Upon the general surface of the 
body the papillae are short, and exceedingly minute, but in other 
situations, as on the palmar surface of the hands and fingers, and on 
the plantar surface of the feet and toes, they are long, of comparatively 
large size, and very numerous; they are also found in great abund- 
ance on the prolabium of the lips, on the nipples, on the glans penis, 
the glans clitoridis, and nymphae. Weber estimates the number of 
papillae in ;i square line of the surface of the palm of the hand at 150 
to 200 simple and 81 compound papillae. They also differ in their 
arrangement in the situations above cited; thus, on the general sur- 
face, they are distributed at unequal 1 distances, singly and in groups, 
whereas, on the palms and soles, and on the corresponding surface 
of the fingers and toes, they are collected into little square clumps, 
containing from ten to twenty papillae, and these little clumps are 

1 Microscopical Journal arftl Transactions, vol. i. 1853, p. 262. 



36 ANATOMY OF THE SKIN. 

disposed in parallel rows. It is this arrangement, in rows, that gives 
rise to the characteristic parallel ridges and furrows which are met 
with on the hands and on the feet. The papillae, in these little square 
clumps, are for the most part uniform in size and length, but every 
here and there one papillae may be observed which is longer than the 
rest. The largest papillae of the derma are those which produce the 
free border of the nail; they occupy the dermal follicle of the nail, 
and are long and filiform. In structure the papilla is composed of 
homogeneous nucleated and fibrillated areolar tissue, bounded by a 
structureless limitary membrane, and containing either a capillary 
loop (vascular jyajnlla) or a nerve fibre (nervous papilla). Modern re- 
searches 1 have shown that the papillae of the skin are properly divisi- 
ble into vascular and nervous ; that in the vascular papilla a nerve is 
rarely found; 2 while in the nervous papilla a capillary loop is equally 
absent; and that those exceptional papillae which contain both a vessel 
and nerve may be regarded as a result of the fusion of two papillae of 
different kinds. The nuclei or endoplasts of the homogeneous areolar 
tissue are oval in shape, and lie with their long axis sometimes 
parallel with the boundary' of the papilla and sometimes horizontally; 
and from these nuclei are thrown off rudimentary elastic fibres which 
give a fibrillated character to the tissue. In the nervous papillae, 
Wagner has described an oval or pine-shaped mass which occupies 
the centre of the papilla, and has been named, from its relation to the 
nerve-fibre, corpusculum tactus ; and by Kolliker, from its situation, 
axile corpuscle. The axile corpuscle is found only in the nervous 
papillae, and is composed of the same homogeneous nucleated areolar 
tissue as the rest of the papilla, but somewhat more dense in its 
nature, and having its nuclei and elastic fibres disposed transversely 
to the axis of the corpuscle. The axile corpuscle has been compared 
to the Pacinian corpuscles of the cutaneous nerves of the hand, and, 
like the Pacinian corpuscle, has been shown by Huxley 3 to be a 
development of the neurilemma of the nerve-fibre ; to be, in fact, the 
"continuation and termination" of the neurilemma of the nerve; not 
surrounding the cylinder of the nerve-fibre equally as in the Pacinian 
body, but swelling out more on one side than on the other, and ex- 
tending for a greater or lesser distance beyond the end of the nerve. 
From the relative position of the nerve-fibre, and the mass of the 
corpuscle, the fibre, after breaking up into its ultimate threads, has 
the appearance of ramifying upon the axile body, and its ultimate 
fibrils are gradually lost in the tissue of the corpuscle, at a greater or 
less distance from its extremity. Nervous papillae, provided with an 
axile corpuscle, have been principally found in the hand and fingers, 
on the red edges of the lip, and at the point of the tongue. 

The arteries of the derma, which enter its structure through the 
areolae of the under surface of the corium, speedily divide into innu- 

1 Wagner; Meissner; Kolliker; Huxley. 

2 Kolliker finds nerves in the vascular papillae of the lip. 

3 On the Structure and Relation of the Corpuscula Tactus (Tactile Corpuscles or 
Axile Corpuscles), and of the Pacinian Bodies. By Thomas H. Huxley, F. R. S., in 
the "Quarterly Journal of Microscopical Science," vol. ii. 1854. 



• NERVES OF THE DERMA. 37 

merable intermediate vessels, which form a rich capillary plexus in 
the texture of the superficial stratum of the derma, and in its papillary 
layer. In the former situation the capillary rete is horizontal — that 
is, it corresponds with the plane of the surface of the skin; while in 
the papillae it is necessarily the reverse of this, namely, perpendicular 
to the plane of the surface. To see the capillary plexus of the papillae, 
it consequently becomes necessary to examine the injected skin by 
means of a vertical section; but if the horizontal rete is to be ob- 
served, no section is needed. In the papillae of some parts of the 
derma, the capillary vessels form simple loops, but in other papillae 
they are convoluted to a greater or less extent, in proportion to the 
size and importance of the papillae. (Plate II., figs. 3, 5.) The capil- 
lary rete of the horizontal stratum presents, as may be inferred, a 
number of circular areae, some of which appear to correspond with 
the bases of the papillae, while the greater number occupy the walls 
of the passages through which the sudoriferous ducts and hairs make 
their way to the surface. After a certain extent of course, the inter- 
mediate vessels unite to form the veins by which the blood circulated 
in the skin returns to the system. 

The lymphatic vessels probably form in the superficial stratum 
of the derma, a plexus, the meshes of which are interwoven with 
those of the capillary and nervous plexus. JSTo lymphatics have as 
yet been discovered in the papillae, nor, indeed, can I imagine that 
they would perform any useful office in that situation. I once suc- 
ceeded in injecting a minute lymphatic plexus in the derma of a 
foetal lamb. 

The nerves of the derma, after entering the areolae of the deeper 
part of the corium, divide into minute fasciculi, which form a terminal 
plexus in its upper stratum. This terminal plexus corresponds with 
the vascular rete, and from it are given off the primitive nerve-fibres, 
which enter the papillae, and terminate in the axile corpuscles. The 
belief has long prevailed, that the distribution of the nerve-fibres in 
the papillae takes place by means of loops, but more careful re- 
search throws doubt over this mode of termination. Mr. Huxley, 1 
who has seen such loops in the cutaneous papillae of fishes, observes : 
"I have never been able to convince myself of their presence (in 
man); and frequently when I believed I had such cases before my 
eyes, the use of a higher power, or the causing the papillae to turn a 
little, would undeceive me. On the other hand, it is by no means 
difficult to obtain the clearest possible evidence of the occurrence of 
the so-called free ends." According to the same observer, the termi- 
nation of the nerves takes place "by one or two pointed extremities, 
which appear to be continuous with the tissue of the corpuscle." As 
already stated, nerve-fibres arc chiefly found in the non-vascular ner- 
vous papillae, and are constantly associated with the axile corpuscle, 
the corpusculum tactus. 

The nerves of the derma, previously to reaching the base of the 
corium, and while yet imbedded in the subcutaneous areolar tissue, 

1 Loc. citat. 



38 ANATOMY OF THE SKIN. 

are remarkable for the presence, on their smaller twigs, of minute, 
oval-shaped, glistening bodies, first described by Pacini, and thence 
named Pacinian corpuscles. The Pacinian corpuscles have been 
chiefly found in the most sensitive parts of the skin, as the palm of 
the hand and sole of the foot, and especially on the pulps of the fin- 
gers; and it has been calculated, that in the palm of the hand and 
palmar surface of the fingers there exist about six hundred of these 
bodies. They vary in size from half a line to three lines in length; 
and, clustered around the small twigs of the nerves, have very much 
the appearance of buds upon the branch of a tree. The Pacinian 
bodies are commonly described as composed of from twenty to sixty 
concentric layers or capsules of areolar tissue, having between them 
as many spaces, which contain a serous fluid, and in the centre an 
oval-shaped cavity, also containing fluid and the axis cylinder of a 
nerve-fibre denuded of its medulla and sheath, and terminating by a 
small round tubercle, or by a bifid or trifid extremity. Mr. Huxley, 
however, who confirms the analogy subsisting between the axile cor- 
puscles and the Pacinian bodies, observes: That there are no spaces 
rilled with fluid between the capsules; that the so-called capsules or 
layers are united by a transparent, granular, or fibrillated substance ; 
that there is no central cavity, but a central solid homogeneous sub- 
stance, which envelops the nerve-fibre, and in which the nerve-fibre 
ends; that the appearance of concentric capsules is produced by the 
parallel arrangement of the nuclei of the connective tissue and 
their elastic fibres ; that, in a word, the Pacinian bodies are nothing 
more than thickened processes of the neurilemma of the nerve, and 
differ from the tactile corpuscles only in the degree of thickening and 
manner of disposition of the neurilemma. 

Recognizing, therefore, the analogy of the Pacinian corpuscle with 
the axile corpuscle of the papilla, and observing that both exist in the 
most sensitive parts of the skin, and notably in parts where a special 
tact is resident, we are led to the conclusion, that they perform an 
important part in connection with the sense of touch; and this conclu- 
sion is borne out by tracing the progressive development of similar 
cutaneous organs in other animals. For example, the corpuscles de- 
scribed by Savi, in the skin of the torpedo, consist of a pedunculated 
capsule of homogeneous connective tissue, containing a clear gelatin- 
ous substance, and at the junction of the peduncle a small prominence, 
in which are found a vessel and the termination of a nerve. Now, 
the analogy of this organ with a Pacinian body is clear enough; but 
if, as Mr. Huxley remarks, a hair be produced on this vascular and 
nervous prominence, and this hair issue from the opposite pole of the 
capsule, the hair would be a sensitive vibrissa, the most fully de- 
veloped form of this series of cutaneous organs. While, if the Savian 
corpuscle be supposed to be magnified in size, it would represent an 
eyeball, one of the highest organs of sense, of which the capsule is the 
sclerotic coat, the gelatinous substance, the vitreous humor, and the 
prominence of the peduncle the point of penetration of the optic nerve 
and the vessels of the retina. A similar analogy may be traced with 



STRUCTURE OF THE EPIDERMIS. 39 

the organ of hearing ; and all the organs of sense may thus be shown 
to be developed according tp one simple and primitive plan. 

The epidermis (Plate I.) is a membrane of defence spread out upon 
the surface of the derma. As we have previously observed, this 
membrane presents a difference of density according as it is viewed 
from its outer or its inner surface ; the outer or free surface being 
dense and horny, the inner or attached surface being soft and com- 
posed of cells. Moreover, the epidermis is laminated in its structure, 
and the laminae present a progressively increasing density, as they 
advance from the inner to the outer surface. This difference in 
density is dependent on the mode of growth of the epidermis ; for, as 
the external surface is constantly subjected to destruction by attrition 
and chemical action, so the membrane is continually reproduced on 
its internal surface, new layers being successively formed upon the 
derma, to take the place of the old. 

The mode of development and growth of the epidermis, I have 
made the subject of careful investigation ; and as the results at which 
I have arrived present a new view of the mode of growth of cells, to 
that founded on the authority of Schwann, and generally received, I 
make no apology for quoting entire the paper 1 in which these observa- 
tions are detailed : 

"It is the commonly received doctrine at the present day that the 
cells of the epidermis, and of epithelium in general, originate out of 
materials furnished by the liquor sanguinis or plasma of the blood. 
In order that this purpose may be effected, the liquor sanguinis is 
conveyed by endosmosis through the walls of the capillary vessels, 
and through the peripheral boundary of the surface, the 'basement 
membrane' of Bowman. Having reached the exterior plane of the 
latter, the changes commence which result in the development of 
granules in the previously fluid liquor sanguinis, or rather, perhaps, 
in the aggregation of the molecules of the organizable material or 
blastema which was previously held in intimate suspension or solution 
by the liquor sanguinis. Out of the body, an action of this kind 
would be termed coagulation, and where inorganic matter is con- 
cerned, crystallization ; and the process to which I am now referring, 
though taking place within the body, is analogous to these phenomena, 
with the difference of being controlled and directed by the power of 
life, of being, in point of fact, a vital coagulation or crystallization. 
Indeed, coagulation, though occurring out of the body, and sometimes 
after the lapse of a considerable period, may be regarded as the last 
act of vital existence, or as a vestige of the atmosphere of life with 
which the coagulating fluid was previously charged in abundance. 

" As regards the tissue under consideration, there is every ground 
for belief that the organizable material or blastema of the liquor san- 
guinis is appropriated by the epidermis the very instant it reaches the 
exterior plane of the 'basement membrane,' some portion of it, and 
the greater part of the serum of the liquor sanguinis, being taken up 
by the newly-formed cells to be transmitted in succession to more 

1 This paper was read before the Royal Society, June 19, 1845. 



40 ANATOMY OF THE SKIN. 

superficial ranges of cells, and the remaining portion being converted 
on the spot into the primitive granules of .the tissue. This belief is 
supported by the fact of the absence of any fluid stratum between the 
epidermis and the derma, and by the close connection known to sub- 
sist between those two membranes. It is well known that to separate 
the epidermis from the derma until the former is so thoroughly satu- 
rated with fluid by maceration as to have acquired a considerable 
addition to its dimensions in all directions, or until decomposition has 
commenced, is next to impossible ; and in the living state of the body, 
separation never takes place until the mutual connection between the 
layers has been destroyed by the effusion of fluid. The microscope 
gives additional weight to this evidence ; I have observed that the 
cells of the deep surface of the epidermis are in immediate contact 
with the boundary limit of the derma, and that, moreover, it is 
frequently difficult to determine the exact line between them. I have 
also made the following experiment : I cut very thin vertical slices of 
the skin at daily periods from the moment of death until decomposi- 
tion had become established, and submitted them to the action of the 
compressor beneath the microscope ; but in every instance, while fresh, 
the two tissues yielded to the pressure in equal proportion without 
any separation occurring. As soon, however, as decomposition had 
commenced, separation was produced, and in the early stages took 
place with difficulty. This experiment proves that the firm adhesion 
subsisting between the epidermis and derma is not alone due to the 
numerous inflexions of the former into the latter which take place at 
the sudoriferous tubes, hair tubes, and sebiferous ducts, although 
these inflexions must co-operate powerfully in the result. 

" Being desirous of examining the under surface of the epidermis 
with the higher powers of the microscope, and failing in all my attempts 
to effect this object by taking the entire thickness of the epidermis or 
by scraping, I awaited the first indication of its separation 1 from the 
derma, and then removing it carefully, made a thin slice parallel with 
the surface which I wished to examine. This plan succeeded beyond 
my expectations ; for not only did I obtain parts so diaphanous as to 
enable me to see the surface distinctly, but the septa between the 
depressions for the papillae of the derma afforded natural laminae of 
such transparency as permitted their structure to be well examined. 

" When the under surface of the epidermis was exposed to view, I 
found it to be composed of four kinds of elements, arranged in such a 
manner as to constitute an irregular mosaic plane. These elements 
are — 1. Granules, measuring about 2 oooi5 °f an * ncn m diameter; 2. 
Aggregated granules, measuring about j-tj^uu > ^* Nucleated granules, 
measuring 5f / 0? y to TT / 7)n ; and 4. Cells, measuring 3^5^ to 5^5 of an 
inch. (Plate I., fig. 8.) 

" The granules, which I may distinguish by the name of primitive 
granules, are globular in form, homogeneous, solid, brightly illumined 

1 It may be necessary to inform those who are unskilled in the manipulations required 
in pursuing investigations in minute anatomy, that no decomposition had occurred in 1 1 1 i .-> 
case; both epidermis and derma wire perfectly fresh, and the separation resulted chiefly 
from the imbibition of water by the epidermis. 



DEVELOPMENT OF THE EPIDERMIS. 41 

by transmitted light when the centre is under the focus of the micro- 
scope, but dark when viewed upon the surface, the darkness being 
increased whenever they are congregated in clusters. These granules 
I conceive to be the first organic shape of the blastema of the liquor 
sanguinis. 

" The aggregated granules, measuring about T q ooo °f an ^ ncn in 
diameter, are minute masses, composed of four, five, or six of the pre- 
ceding, or as many as can be aggregated without leaving an unoccu- 
pied space in the centre of the mass. With an imperfect focus, these 
granules have the appearance of possessing a transparent globular 
nucleus ; but this appearance ceases when the focus is perfect, and then 
the component granules are quite obvious, and the centre becomes a 
dark point, namely, the shadow caused by the meeting of the primi- 
tive granules. 

"The nucleated granules, measuring between %-q-qq and ^otj °f an 
inch in diameter, are in point of construction an 'aggregated granule,' 
with a single layer of aggregated granules arranged around it, so as 
to give the entire mass a circular or oval form. The central 'aggre- 
gated granule' has now become a nucleus, and at the same time has 
undergone other changes, which indicate its longer existence. For 
example, the primitive granules composing it are denser than they 
were originally, and they are separated from each other by a very 
distinct interstitial space, filled with a transparent and homogeneous 
matter. Sometimes this , interstitial substance presses the granules 
equally on all sides, constituting a circular nucleus; but more fre- 
quently two opposite granules are more widely separated than the 
rest, and the nucleus receives an elongated form. The interstitial 
substance is most conspicuous at the line of junction of the nucleus 
with the secondary tier of 'aggregated granules,' and in this situation 
gives a defined character to the nucleus. Close observation and 
a perfect focus render it quite obvious that the peripheral tier of 
granules are in reality aggregated. They are lighter than the shaded 
granules of the nucleus, and apparently softer in texture. 

"The nucleated granules are more or less flattened in their form, 
and present a flat surface of contact with the derma. It is this latter 
circumstance that gives the facility of determining their mode of con- 
struction. 

"The cells of the deep stratum of the epidermis, measuring %-q^-q 
t0 .'oVo °f an i ncn i n their longer diameter, are the most striking 
feature of this layer, and may be said to be. its chief constituent. 
They originate, as is evident from their structure, in the nucleated 
granules previously described, and consist of a transparent layer 
added to the exterior of the former. Or, if I might be permitted to 
describe them as they appear in their tessellated position, they are con- 
stituted by the addition of a transparent border to the last described 
nucleated granule. The periphery of this transparent border is 
bounded by a dark interstitial substance, which gives the border a 
defined outline, and in the latter situation I imagine a cell-membrane 
to exist. 1 am not satisfied, however, that this is the case, and the 
difficulty of isolating these cells, and their roughness of outline when 



42 ANATOMY OF THE SKIN. 

separated, seem to prove that if a membrane be really present, it 
must be exceedingly thin and easily torn. Assuming, therefore, from 
analogy rather than from demonstrative evidence, that there exists 
a boundary membrane to the bodies I am now describing, I have 
termed them 'cells;' the cavity of the cell I apprehend to be 'the 
transparent border ;' the 'nucleated granule' is the nucleus of the cell; 
the 'aggregated granule' of the latter the nucleolus; and the entire 
body a 'nucleolo-nucleated cell.' 

"Before quitting the structure of the 'nucleolo-nucleated cell,' or 
primitive cell of the epidermis, there is a point of much interest to 
be mentioned with regard to it, which is, that the ' transparent border' 
just described is itself a tier of 'aggregated granules.' The nucleolus, 
therefore, is an 'aggregated granule,' the nucleus a tier (taking its 
flat surface) of aggregated granules surrounding the former, and the 
cell-chamber a tier of aggregated granules inclosing the whole. 

" To return to the mosaic-like plane of the under surface of the 
epidermis: the largest of the pieces composing this plane are the 
nucleolo-nucleated cells. These are placed without order ; in some 
parts closely pressed together, in others at short distances apart, and 
here and there leaving interspaces between them equal to the breadth 
of the cells. The interspaces or intercellular spaces are occupied by 
the 'nucleated granules,' 'aggregated granules,' and 'primitive gra- 
nules,' irregularly set in a homogeneous interstitial substance, which 
fills up all vacuities. The granules and interstitial substance modify 
the light transmitted through them variously at different foci of the 
microscope ; sometimes the granules look dark, while the interstitial 
substance is light, and sometimes the reverse is the case. 

"Such is the structure of the mosaic-like plane of the under surface 
of the epidermis ; and so far, my observations, having reference to 
facts, are demonstrable, and admit of being spoken to 
Fig. A. positively. The interpretation of the facts I would 

willingly leave to others, but feel that I am called upon 
to state any opinion, founded on the above observations, 
that I may have formed of the signification of these ap- 
pearances. In the first place, then, I must acknowledge 
myself wholly divided between a belief in the possibility 
of formation of the ' aggregated granule' by the aggre- 
face of the scarf- gation of primitive granules, the idea which prompted me 
skin, showing the to give it that name ; and the formation of the ' aggre- 
mosaic - like ap- pr a tcd granule' by the cleavage of a primitive granule. If 
newly" 06 - formed tn ' s question related merely to the formation of the 
surface. ' primary aggregated granule' it would be unimportant, 

but it has a more extended application. The utter- 
most layer of the nucleus is composed, as I have shown, of ag- 
gregated granules, and so also is that layer which alone forms the 
chamber in the nucleolo-nucleated cell. To these the hypothesis of 
cleavage of a single granule would be most suitable, and this theory 
would explain, better than any other, changes which remain to be 
described in the further growth of the epidermal cell. In the second 
place, the relation of cell and nucleus is a question on which I feel 




GROWTH OF THE EPIDERMIS. 43 

considerable doubt. The process of development appears to consist 
in the successive production of granules, one layer of granules suc- 
ceeding another, so that, if the organizable principle exists in each 
separate granule, the organizable force may be supposed to be more 
and more weakened in successive formations until the moment ar- 
rives when it ceases entirely. Is that which I have described as a 
' nucleolo-nucleated cell' really a cell or still a nucleus ? The only so- 
lution of the question that occurs to me is, determining the presence 
of a cell-membrane, in which I have not satisfactorily succeeded. 

"Admitting the nucleolo-nucleated bodies now described to be cells 
in their earliest state of formation, their size is 3^00 to 25*00 °f an 
inch in the long diameter, and that of their nucleus from g J U5 to 4^0^ 
of an inch. In the stratum immediately above the deepest layer I 
find cells measuring o-oso °f an ^ nc ^ w ^ tn nuclei of 45*00- Above 
these, cells measuring ygoo? w ith nuclei varying from ^oo to 3^00' 
and above the latter, cells measuring T J CI with nuclei of 35^. I n 
following the layers of epidermis upwards to the surface, cells may be 
observed possessing every intermediate degree of size between the 
last-named cell, namely, yj^ and g ^, which is the measurement of 
the scales which constitute the uppermost stratum of the epidermis. 
It must not be supposed, however, that the growth of the epidermal 
cells reaches its maximum only at the surface ; I have found cells of 
that magnitude in the deeper strata, and there is every indication of 
the growth of these cells being completed in the stratum immediately 
above the mosaic-like layer. 

" Young cells are remarkable for the large size of the nucleus as 
compared with the entire bulk of the cell, and it is quite evident also 
that the nuclei, up to a certain point, grow with the cells ; their mode 
of growth appearing to be the separation of the original granules by 
the deposition between them of interstitial matter, and in addition, as 
I believe, by cleavage and the consequent multiplication of the granules ; 
in cells measuring ^Vc and Tg ^^ of an inch, I found the granular 
character of the nucleus to be very manifest. Besides growth, it is 
apparent that other changes are taking place in the nucleus ; imbibi- 
tion and assimilation of organizable material must necessarily be in 
action in order to accomplish the formation of interstitial matter ; but, 
in addition to this, the central granules undergo another change, by 
which they are altered in character, and become distinguished from 
the rest when submitted to chemical experiment. For example, when 
diluted acetic acid is added to the cells measuring 3^5 of an inch and 
less, the entire nucleus is rendered transparent and less discernible than 
before ; but when cells of a somewhat larger size, and consequently 
longer growth, are submitted to the same process, the nucleus is ren- 
dered much more distinct than it was previously. But the body which 
is made bo conspicuous in this latter experiment is not the entire 
nucleus, but simply the central and older granules of the nucleus; the 
younger granules retain the character of those of the young cells : they 
are made more transparent than they were before, and have faded from 
sight. I may mention, also, that the nucleus brought into view by 
the acetic acid is more or less irregular in form, and has the appear- 



44 ANATOMY OF THE SKIN. 

ance of being constituted by the fusion of the original granules. How 
much of this appearance may be real, and how much the effect of the 
acid, I do not pretend to say ; and I set no value on the experiment 
beyond the demonstration of the mere fact which it is made to illus- 
trate. 

"I now turn to the growth of the cells: I have remarked, in an 
earlier paragraph, that the formation of the young cell appears to be 
due to the development of a stratum of ' aggregated granules' exter- 
nally to the nucleated mass which I have regarded as the cell-nucleus. 
Now, nothing is more certain than that the growth of the cell is due 
to a successive repetition of this process ; the growth of the cell-mem- 
brane being consentaneous with the development and growth of aggre- 
gated granules within it. In cells of yg^ to T5 ^ of an inch, the 
aggregated granules of the periphery are not easily discernible, but in 
cells measuring y^oo' an( ^ thence upwards to the complete size of the 
epidermal cell, the fact is quite evident, and is apparent even in the 
cell-scale. Indeed, a cell at the full period of growth is a kind of cell 
microcosm, containing in its interior, secondary cells, tertiary cells, 
nucleolo- nucleated cells, nucleated granules, aggregated granules, and 
primitive granules. (Plate I., fig. 8, H.) 

" It will be observed that this hypothesis of cell-growth differs from 
that of Schwann. The theory of Schwann always appeared to me to 
be incompetent to the explanation of the growth .of the large scale of 
epidermis and epithelium in a tissue manifestly subjected to consider- 
able pressure. I sought in vain for the watch-glass cells, elliptical 
cells, and globular cells in the epidermis, and my search has been 
rewarded by the discovery of the above described beautiful process of 
formation and growth. It will be seen that, according to this view of 
the growth of epidermal cells, they never possess anything approach- 
ing to a globular form ; that the scales are not flattened spheres, but, 
on the contrary, always possessed a flattened form, and have increased 
by a peripheral growth. This mode of growth, again, is made mani- 
fest by the observation of a vertical section of the epidermis. The 
most careful examination can distinguish no difference between the 
size of the deeper and superficial strata of cells : they have all the same 
average thickness, all the same average length, an appearance easily 
explained, when we regard them as parent cells, containing secondary 
and tertiary cells of the same average size as the cells of earlier forma- 
tion. It is true, that the complete size of the cell is very quickly 
attained, and that its growth, taking place in the deepest stratum of the 
epidermis, could not be expected to produce any difference of charac- 
ter in the middle and superficial strata; but this is not mentioned, as 
far as I know, by Schwann. 

" The process of growth here described explains also the fact of the 
disappearance of the nucleus in the scales of the epidermis. The outer- 
most granules of the nucleus have become the nuclei or nucleoli of 
secondary cells, and have consequently been moved away from their 
original position in the performance of the office of centres of growth 
to secondary cells. The original nucleus, therefore, is not lost, but 
merely robbed of some of its component granules, which may be dis- 



GROWTH OF THE EPIDERMIS. 45 

covered in many parts of the epidermal scale, instead of being concen- 
trated in a single mass. In these scales, and particularly in epithelial 
scales, the central and denser part of the original nucleus is generally 
perceptible : in the latter it constitutes the scale-nucleus, and in the 
epidermal scale there is always some one little mass larger than the 
rest, particularly if the scale have been for some time immersed in 
fluid, as when it is examined in the serum of a blister. In an epider- 
mal scale, measuring g ^ °f an mcn i Q long-diameter, I found several 
secondary cells measuring y^oo? others measuring jJj^, and in the 
interstices, primitive granules, aggregated granules, and nucleated 
cells. 

" My observations, it will be seen, have been chiefly directed to the 
epidermis, and I am prevented at present from carrying them further ; 
but I have no doubt that the epithelium will be found to be identical, 
in the phenomena of development and growth, with the epidermis. 
I have observed the same structure in the epithelium of the mouth 
and fauces, and also in that of the bladder and vagina. Incomplete 
epithelial cells from the fauces, measuring g^n an( ^ 7^0 °f an i ncn > 
presented a very remarkable appearance ; they had a rounded tabu- 
lated border, evidently composed of a row of secondary cells, and a 
depressed centre, as though the action were subsiding in the latter 
while it was progressing in the circumference. 

"Another illustration of the structure now described, I found in 
the cells of melanosis, and in the pigment cells of the choroid mem- 
brane of the eyeball, and I am induced to believe that the same struc- 
ture will be discovered more extensively than at present can be an- 
ticipated? The corpuscles of melanosis, according to my observation, 
are parent cells, having an average measurement of y^^ of an inch, 
containing secondary cells and nucleated and aggregated granules, as 
well as separate primitive granules. The aggregated granules mea- 
sured fromyy^fl to ? o ] 5(j of an inch, and the primitive granules 
about 9v fo r 

" There is another feature in the history of development of the 
epidermal cell, which I regard 'as peculiarly interesting. This relates 
to an organic change taking place in the assimilative powers of the 
primitive granules, by which the latter are altered in their color ; in 
short, are converted into 'pigment granules.' Pigment granules 
appear to differ in no respect from the primitive granules, excepting 
in tint of color and chemical composition. They have the same 
globular form, the same size, and occupy the same position in the 
cell, being always accumulated around the nucleus, and dispersed less- 
numerously through the rest of the cell. The nucleus of the cell in 
the epidermis of the negro appears to consist wholly of pigment 
granules; while, in the European, there is a greater or less admixture 
of colored and uncolorcd granules. The central granules are gene- 
rally lighter in tint than the rest, and give the idea of a colorless 
nucleolus, while those around the circumference are more deeply 
colored. Besides a difference in the depth of color of the separate 
granules entering into the composition of a single cell, there is also 
much difference in the aggregate of the granules composing particular 



4tf ANATOMY OF THE SKIN. 

cells. For example, intermingled with cells of a dark hue, there are 
others less deeply tinted, which give the tissue in which they are 
found a mottled appearance. This fact is well illustrated in the hair 
and also in the nails ; in which latter it is no uncommon thing to find 
an isolated streak produced by the accumulation of a number of cells 
containing colored granules in the midst of colorless cells. 

" When pigment granules are examined separately, they offer very 
little indication of the depth of color which is produced by their 
accumulation. I have observed some to have the hue of amber, while 
others scarcely exceeded the most delicate fawn. The depth of color 
of the deep stratum of the epidermis in the negro is evidently due to 
the composition of that layer, of these granules chiefly, while the 
grayness of the superficial layers of the same tissue results not merely 
from the desiccation of these granules, but also from the fact of those 
subsequently produced being less strongly colored, and also from the 
addition of a considerable mass of colorless cell membrane. The 
epidermal scale of the negro has a mottled appearance, from the 
numerous secondary nuclei, and their attendant colored granules, 
which are scattered through its texture." 

It follows, from a review of the structure of the epidermis, that this 
membrane is accurately modelled on the papillary layer, that each 
papilla finds its appropriate sheath in the newly-formed epidermis or 
rete mucosum, and that each irregularity of surface of the former has 
its representative in the soft tissue of the deep layers of the latter. 
(Plate I, figs. 2, 5.) It is not, however, the same with the external 
surface of the epidermis; this is modified by attrition and exposure to 
chemical and physical influence; the minute elevations, corresponding 
with the papillae, are, as it were, polished down, and the surface is 
consequently rendered smooth and uniform. The palmar and plantar 
surfaces of the hands and feet are an exception to this rule, for in 
these situations, in consequence of the large size of the papillae, and 
their peculiar arrangement in rows, ridges corresponding with the 
papillae are strongly marked on the superficial surface of the epider- 
mis. (Plate I, fig. 1.) Moreover, upon the borders of the fingers, 
where the linear-disposed and magnified papillae of the palmar surface 
gradually pass into the irregular and minute papillre of the dorsal 
surface, a transition state of the epidermis may usually be observed. 

Besides the form bestowed upon the epidermis by its relation with 
the derma, its degree of thickness will be found to be dependent upon 
the same source, and to bear an accurate proportion to the degree of 
development of the papillae. Thus, on the palms 1 of the hands, where 
the papillae are large, the epidermis is thick ; while on the backs of 
those organs, or on the scalp, where the papillae are small, it is ex- 
ceedingly thin. 

Another character presented by the epidermis is also to be consi- 
dered as the consequence of its connection with and dependence on the 

1 In an individual not exposed to much manual labor, I found the epidermis in the 
palm of the hand to measure one-fourth of a line in thickness. The horny covering 
of the foot of the dog is formed by papilla? of unusually large size, and highly vas- 
cular. 



STRUCTURE OF THE EPIDERMIS. 47 

derma — namely, the network of linear furrows, which every where 
intersect each other, and trace out the surface into small polygonal 
and lozenge-shaped areas. These lines correspond with the folds of 
the derma produced by its movements, and are most numerous where 

Fig. B. 




those movements are greatest, as in the flexures, and on the convex- 
ities of joints. Some difference is perceived in the form of the areas, 
when examined in these two situations ; thus, in the flexures of the 
joints they are narrow and long, and, for the most part, lozenge- 
shaped in their figure, while on the convexities of joints, as upon the 
elbow and knee, the areas are large, and more nearly quadrangular. 
The furrows of the epidermis admit of a division into two kinds, — 
namely, those which correspond with joints, and bear relation to the 
movements of the body and limbs, and those which belong especially 
to the movements of the skin. The first or larger kind are those 
which are so perceptible on the flexures and convexities of joints, and 
on the palm of the hand and the sole of the foot. The latter or 
smaller occupy the interspaces of the former, and those parts of the 
surface where the furrows of articular motion have no existence. 
Their plan of arrangement is as follows: from each of the hair-pores 
(«, a) there pass off on all sides, like rays from a centre, from six to 
ten^ lines, which meet by their extremities lines proceeding from other 
pores. These lines mark out the surface into small triangular spaces 
(b, b), or areas, within which are other and more minute pores, proba- 
bly perspiratory pores. From the latter a similar number of radiating 
lines are given off, and abut against the coarser lines, dividing the 
surface into smaller triangular arose (e, e), and giving to the entire net- 
work the appearance of a number of nicely-adjusted angular wheels. 
On the shoulder of a child of about five years of age, I counted sixty 
of the hair-pores with the wheel-like rays within the limit of a square 
inch ; while between these larger pores were six hundred smaller 
pores, constituting so many secondary centres and secondary wheels, 
and forming an elegant mosaic pattern. On the scalp, the furrows 
run between the hair-pores, and the included areas are more open than 
on the general surface of the skin. 

The deeper tint of color of the skin observable among the nations 
of the South, and in certain regions of the skin of the European, is 
due to the presence of pigment granules in the cells of the epidermis. 



48 ANATOMY OF THE SKIN. 

The pigment-bearing cells are most abundant in the furrows of the 
derma, and in the hollows between the papillae. The production of 
pigment granules is not, however, limited to the horizontal stratum of 
the derma : they are also met with in the various inflexions of the 
epidermis, constituting the lining of the sudoriparous and sebiparous 
glands, and hair-follicles. It is in consequence of the presence of these 
granules in the cells composing these inflexions that we are enabled 
to perceive the organs to which they belong with greater facility ; and, 
for the same reason, we discover pigment granules in the perspiratory 
and sebaceous secretions. 

The chemical composition of the pigment of the skin may be 
inferred from the analysis of the pigmentum nigrum oculi made by 
Scherer. 1 The principal elementary substances composing this pig- 
ment, and also composing the epidermis, were found in the following 
proportions : 

Pigment. Epidermis. 

Carbon, 58.27 50.34 

Hydrogen, 5 97 6.81 

Nitrogen, 13 76 17 22 

Oxygen, "21.98 25.63 

The proximate composition of the epidermis, according to an analy- 
sis by John, is as follows : 

Hardened albumen, . . 93.0 to 95.0 

Gelatinous matter, . . 5.0 " 

Fat 0.5 " 

Lactic acid : salts and oxides, 1.0 " 

The salts are lactate, phosphate, and sulphate of potash; sulphate and 
phosphate of lime; and sulphate and phosphate of ammonia; the 
oxides, those of manganese and iron. 

The identity of structure of the external tegument or skin, with the 
internal tegument or mucous membrane, has long been established. 
In both the same parts are found, and each is continuous with the 
other. Mr. Bowman directs our notice 2 to this fact, and adduces an- 
other point of similitude between these membranes. He finds beneath 
the epithelium of mucous membranes, on the one hand, and in contact 
with the vessels of the parenchyma on the other, " a simple, homoge- 
neous expansion, transparent, colorless, and of extreme tenuity;" this 
delicate expansion serves as a foundation on which the epithelium 
rests; and in accordance with this view he terms it the "basement 
membrane." This is, in fact, the boundary layer of all vascular mem- 
branes, and as such is met with in serous as well as in mucous 
structures. The extreme tenuity of the basement membrane may be 
inferred from the measurements instituted by Mr. Bowman ; in the 
uriniparous tubuli its thickness does not exceed 2B ^o of an inch; in 
the seminiparous tubuli, it is T <5o <j of an inch in thickness; in the 
lungs, it forms almost the entire thickness of the air-cells; and in no 
situation has it been found to exceed g^g^ of an inch. Reasoning 
from analogy, he infers the existence of a corresponding membrane on 

1 Liebig, Organic Chemistry. 

2 Cyclopedia of Anatomy and Physiology ; Article, Mucous Membrane. 



SUDORIPAROUS SYSTEM. 49 

the surface of the derma — an inference that will be unreservedly ac- 
corded him ; but he finds it difficult to demonstrate this membrane in 
the latter situation, in consequence of its close adherence to the vascu- 
lar rete, and deeper seated stratum. The same difficulty exists on the 
general surface of the mucous membranes, and for the same reason ; 
•but, in the minute tubuli of the secreting glands, the connection be- 
tween the basement membrane and the vascular rete is so slight, that 
they separate on the gentlest pressure. In like manner he finds no 
difficulty in distinguishing this membrane in the tubuli of the sudori- 
parous and sebiparous glands ; and he remarks, that it is it which gives 
firmness and form to the minute tubuli of secreting glands. 

SUDORIPAROUS SYSTEM. 

The sudoriparous GLANDS (Plate II., fig. 3) are situated in the 
middle and deeper stratum of the corium — namely, at about half a 
line below the plane of the upper surface of the epidermis, and also 
in the subcutaneous cellular tissue. They are small round or oblong 
bodies, of a reddish-yellow color, and composed of the convolutions 
of a minute tube, which commences by a coecal extremity, and after 
quitting the gland, mounts to the surface of the epidermis and becomes 
its efferent duct. The efferent duct ascends through the structure of 
the derma and epidermis, to terminate by a funnel-shaped and oblique 
aperture or pore upon the surface of the latter. The sudoriparous 
glands are found in every part of the body with the exception of the 
inside of the concha and the meatus auditorius, 
and they present considerable differences of size Fig. C. 
in different regions. They are smallest on the 
eyelids, the nose, the pinna of the ear, the penis, 
and the scrotum, where they average T £ 7 of an \ 
inch in diameter ; and largest in the areola of 
the mamma, at the base of the scrotum and penis, 
and in the axilla — in the latter situation reach- / c 
ing a size of half a line to a line and a half. 
The common average of bulk of these glands in 
their general distribution is g 1 ^ of an inch ; and 
in the palm of the hand I found them range 
between 5 ]U and T i,v of an inch. The entire .„_•„♦ i—* „■♦>, 

r i 11 • • i • i perspiratory gland with 

length ol each tubulus, comprising that which its tubule. 

constitutes the gland, as well as the excretory «• Th » pore. &. That por - 

duct, is about one quarter of an inch. The t! ° n ° f , the < ube wb ! cb . ia 

_ ' . T- ... situated in the scarf-skin ; 

efferent duct presents some variety in its course the spiral is close, c. The 
upwards to the surface. Below the derma it is tube within the sensitive 
curved and serpentine; and having pierced the Bkin; the 8piral is more 

■i . p , *. , .. .. •. i open than the preecdiiii,'. 

derma, it tne epidermis be thin, it proceeds more d , Thegiand. 

or less directly to the excreting pore. Sometimes 

it is spirally curved beneath the derma, and having- passed the latter, 

is regularly and beautifully spiral in its passage through the epidermis, 

— the last turn forming an oblique and valvular opening on the surface. 

4 



50 ANATOMY OF THE SKIN. 

The spiral course of the duct is especially remarkable in the thick 
epidermis of the palm of the hand and the sole of the foot. In those 
parts of the body where the papillae of the derma are irregularly 
distributed, the efferent ducts of the sudoriparous glands open on 
the surface also irregularly, while on the palmar and plantar surface 
of the hands and feet, the pores are situated at regular distance's 
along the ridges, at points corresponding with the intervals of the 
small square- shaped clumps of papillae. (Plate I., fig. 1 ; Plate II., 
fig. 1.) Indeed, the apertures of the pores seen upon the surface of 
the epidermal ridges give rise to the appearance of small transverse 
furrows, which intersect the ridges from point to point. On the palm 
of the hand and palmar surface of the fingers the sudoriparous pores 
are situated at about one-sixth of a line apart along the ridges, and at 
a little less than a quarter of a line from ridge to ridge. On the heel 
there are four and a half pores in the compass of a line along the ridge, 
and three and a half across the ridges. 

Krause estimates the total number of sudoriparous glands of the 
entire body, exclusive of those of the axilla, which are so numerous as 
to form almost a continuous layer beneath the corium, at 2,381,248. 
On the cheeks, the back of the trunk, and thighs, he estimates the 
number in a square inch of surface at 400 to 600 ; on the rest of the 
trunk of the body, the forehead, neck, forearm, leg, and back of the 
hand and foot, at 924 to 1090 ; in the palm of the hand, at 2736; and 
in the sole of the foot, at 2685. This estimate is probably somewhat 
too high, but may be accepted as a general idea ; the aggregate bulk 
of these organs, including those of the axilla, he states at 39,653 cubic 
inches. 

The efferent duct and glandular tubulus of the sudoriparous gland 
are lined by an inflection of the epidermis. This inflection is thick 
and infundibuliform in the upper strata of the derma, but soon be- 
comes uniform and soft. The infundibuliform projection is drawn out 
from the duct when the epidermis is removed, and may be perceived 
on the under surface of the latter as a nipple-shaped cone (Plate I., fig. 
2). A good view of the sudoriferous ducts is obtained by gently sepa- 
rating the epidermis of a portion of decomposing skin ; or they may 
be better seen by scalding a piece of skin, and then withdrawing the 
epidermis from the derma. In both these cases it is the lining sheath 
of epidermis which is drawn out from the duct (Plate III., fig. 17). 
The average diameter of the tubular epidermal lining of a sudorifer- 
ous duct examined in the palm of the hand was ^^ of an inch, two- 
thirds of this diameter being constituted by the wall of the tubule, and 
the remaining third by its area. The parietes of the tubule were com- 
posed of two or three layers of cells, of which the most external, namely, 
those which corresponded with the corium, measured 3^3 of an inch 
in diameter. 

The tubule of the sudoriparous gland and that of the efferent duct 
into which it is prolonged are uniform in diameter, and composed of 
two, and, in some instances, of three coats ; the two coats are an outer 
fibrous coat, which is continuous above with the basement membrane 
of the surface of the derma, and an epithelial lining identical in struc- 



SUDORIPAROUS SYSTEM. 51 

ture with the deep layer of the rete mucosum. In certain of the glands, 
especially those of larger size, there is an intermediate coat of smooth 
muscle, and a similar coat is found in the efferent ducts of the glands 
in the axillary region. In these latter, moreover, the efferent duct is 
sometimes seen to bifurcate, and sometimes its branches have been 
observed to divide dichotomously in forming the convolutions of the 
gland. The cavity of the tubule presents two important differences : 
in one it is open for the greater part of the whole of its extent, in 
which case the epithelial lining is distinct ; in the other, the tubule is 
filled with epithelial contents to a greater or less degree, and there is 
no cavity present excepting in the efferent duct. The contents of the 
tubules of the smaller glands are commonly clear and aqueous, while 
those of the larger glands are opaque and grumous, and composed of 
an admixture of cells, entire and broken up, cell-nuclei, and granules, 
suggesting a resemblance with sebaceous substance, and the more so 
as there is also present protein and fat. 1 When, therefore, the tubules 
contain fluid only, the epithelial lining is complete ; but when the con- 
tents are of the mixed character already described, the epithelial lining 
is more or less deficient or entirely absent. Hence the perspiration 
participates in the double mode of secretion common amongst glands, 
namely, transudation and cell elaboration. 

The sudoriparous gland is inclosed in a network of capillary ves- 
sels, which in an injected preparation have a very beautiful appear- 
ance ; but nothing is known as to the arrangement of its nerves. 

Taken separately, the little perspiratory tube, with its appended 
gland, is calculated to awaken in the mind very little idea of the im- 
portance of the system to which it belongs ; but when the vast num- 
ber of similar organs composing this system are considered — for it 
includes the sebiparous glands, which are also agents in perspiration — 
we are led to form some notion, however imperfect, of their probable 
influence on the health and comfort of the individual. I use the words 
"imperfect notion," advisedly, for the reality surpasses imagination 
and almost belief. To arrive at something like an estimate of the 
value of the perspiratory system in relation to the rest of the organism, 
I counted the perspiratory pores on the palm of the hand, and found 
3528 in a square inch. Now, each of these pores being the aperture 
of a little tube of about a quarter of an inch long, it follows, that in a 
square inch of skin on the palm of the hand there exists a length of 
tube equal to 882 inches, or 73 J feet. On the pulps of the fingers, 
where the ridges of the sensitive layer of the true skin are somewhat 
finer than in the palm of the hand, the number of pores on a square 
inch a little exceeded that of the palm ; and on the heel, where the 
ridges are coarser, the number of pores in the square inch was 2268, 
and the length of tube 567 inches, or 47 feet. To obtain an estimate 
of the length of tube of the perspiratory system of the whole surface 
of the body, I think that 2800 might be taken as a fair average of the 
number of pores in the square inch, and 700, consequently, of the 
number of inches in length. Now, the number of square inches of 

» Kolliker. 



.y± ANATOMY OF THE SKIN. 

surface in a man of ordinary height and bulk is 2500 ; J the number 
of pores, therefore, 7,000,000, and the number of inches of perspira- 
tory tube 1,750,000, that is, 145,833 feet, or 48,600 yards, or nearly 
twenty-eight miles. 

The development of the sudoriparous apparatus has been observed 
and described by Kolliker. He discovered small masses of nucleated 
cells resembling buds, growing from the rete mucosum into the derma, 
in the foot of the foetus at the fifth month ; by the sixth month, the 
buds, assuming the form of elongated processes with ceecal ends, had 
reached the mid-thickness of the corium ; by the end of the seventh 
month they had traversed the entire thickness of the corium, and were 
bent at the extremity, beginning to assume the convoluted arrange-'' 
ment they were afterwards to possess. Subsequently they pursued 
their progress with rapidity ; continued cell-multiplication enabled 
them to reach their full length ; the convolutions increased until the 
gland was perfected ; and the central cells yielding to the process 
of softening and liquefaction common to the formation of tubular 
glands, their cavity was established. So that, at the time of birth, 
the sudoriparous system is complete throughout the entire skin. 

SEBIPAROUS SYSTEM. 

The Sebiparous glands (Plate III.) are the special producing or- 
gans of the sebaceous substance or fatty secretion of the skin ; they are 
associated with the hairs, being connected with the upper part of the 
hair-sacs, and, like the hairs, are distributed almost universally over 
the surface of the body. They are situated in the upper part of the 
corium, and are either simple follicular sacs, or more or less subdi- 
vided into branches or lobules, so as to constitute simple racemose and 
compound racemose glands. Opening into the hair-sacs of the scalp 
there exist commonly a pair of these glands to each hair, while in the 
beard and axilla there are more ; and in the mons veneris, labia ma- 
jora, and scrotum, often as many as seven or eight, which surround 
the neck of the hair-sac and have a radiated or rosette-like appear- 
ance. They are whitish in color, and vary in size from the five or six 
hundredth of an inch to a line in diameter. The largest of the sebi- 
parous glands of the body are those of the eyelids, the meibomian 
glands. 

The purpose of the sebiparous organs being to supply the surface 
of the skin with an oily secretion, they are found most abundantly in 
situations where such a secretion- is chiefly required, as among the 
hair, to which they lend their aid in preserving its smooth and glossy 
appearance; on the face, and particularly its more exposed parts, as 
the nose ; in the hollow of the folds of the body, as the axilla and 
pudendum; and around the apertures of junction with the mucous 
membrane, as along the eyelids, and at the anus. The so-called ceru- 
minous glands of the ear-tubes have been shown by Kolliker to belong 

1 Haller's estimate of the extent of surface of the body is fifteen square feet, that is, 2160 
square inches. 




SEBIPAROUS SYSTEM. 58 

rather to the sudoriparous than to the sebiparous system, and are not 

the producers of the cerumen or ear wax, which is a sebaceous matter 

secreted by sebiparous glands, which are as' 

abundant in the meatus auditorius as else- Fig. D. 

where. 

In structure, a sebiparous gland is com- 
posed of membrana propria, or proper invest- 
ing coat, consisting of areolar or connective 
tissue, and an internal epithelial lining of 

nucleated Cells, Which is COntinUOUS through Meibomian glands; natural size: 

its excretory duct with the outer root-sheath bedded in the cartilage of the 
of the hair-sac. The excretory or sebiferous u pp« e y elld - 
duct is the medium of communication be- 
tween the gland and the hair-sac, and its epithelial lining consists of 
several layers ; but in the subdivisions of the gland these layers are 
reduced in number, until in the glandular vesicles of the periphery 
there remains only a single layer. Within the cavity of the gland is 
found a grumous pulp, more or less fluid, consisting of cells containing 
a yellowish and transparent homogeneous substance, others containing 
small globules of oil, and others again filled with oil; this, with some 
free oil and watery fluid, is the sebaceous secretion. It is not a fluid 
secretion, but a cellular secretion. In chemical composition the seba- 
ceous substance, according to Esenbeck, consists of fat, albumen with 
casein, extractive matter, and phosphate of lime, in nearly equal pro- 
portions. 

The sebiparous glands have no special supply of capillary vessels, 
as have the sudoriparous glands; and nothing is known as to their 
nerves. 

Development of the sebiparous glands takes place from the hair-sacs 
between the fourth and fifth month of foetal existence, and follows the 
order of formation of the hairs. The first trace of the future gland is" 
a bud-like prominence of the neck of the hair-sac, derived from and 
consisting of nucleated cells identical with those of. the outer root 
sheath; the bud elongates, and either remains single or divides, and 
by the same process of budding its division continues until the entire 
gland is completed. This completion does not always take place at 
once, but the process may cease for a time and subsequently be 
resumed ; hence, it is continued after birth and during the growth of 
the body, or may be set up in after life as a pathological action. At 
about the sixth month a difference of character is observed between 
the cells of the periphery of the newly-formed gland and those of the 
centre ; the latter becoming darker colored, and are found to contain 
globules of oil: this is the sebaceous secretion. The process of sepa- 
ration of the cells commences at the distal part of the gland, and 
gradually moves onward to the excretory duct, until it reaches the 
Hair-sac; and its secretion-cells are poured out into the hair-sac to be 
distributed on the surface of the skin. The growth of the glands, as 
Well as the formation of the secretion, is a process of cell-multiplica- 
tion, the production of a succession of new cells out of the elements of 
the older or parent cells. 



54 ANATOMY OF THE SKIN. 



Hairs (Plate IV.) arehorny filaments, appertaining to the structure 
of the skin, and distributed more or less extensively and abundantly 
over the surface of the body. Every part of the cutaneous surface is 
organized for the production of hair, with the exception of the palms 
of the hands, the soles of the feet, the dorsum of the ungual phalanges 
both of the hands and feet, and the upper eyelids. They are abundant 
on the head, on the face, in the axillae, on the pubes, and less numer- 
ously dispersed over the trunk of the body and limbs, and they 
present certain special characters, such as shape, size, length, color, 
quantity, and structure, which call for separate consideration. We 
have also to pass in review their mode of growth, their development, 
and their physiological dependence on the rest of the organism. 

A hair admits of a natural division into a middle portion or shaft 
(scapus), and two extremities; a peripheral extremity, the point; and 
a central extremity inclosed within the skin, the root. The root is 
somewhat thicker than the shaft, and cylindrical in figure, while its 
extremity is expanded into a spherical or oval mass twice or three 
times the thickness of the shaft, the bulb. 

The shaft of the hair is rarely perfectly cylindrical ; it is more or 
less compressed or flattened, and oval or fabiform in section. Leeu- 
wenhoeck observes with regard to the shape of the hair, " quot crines, 
tot figurge." This, however, is not strictly true, for the typical figure 
of the shaft of the hair is cylindrical ; and the aberrations from that 
type are more or less flattening in consequence of desiccation by the 
air of that part of the shaft which is emitted from the follicle in which 
its root is contained. Flattening of the shaft gives rise to waving 
and curling hair ; and in hair which is much curled the flattening is 
more or less spiral in direction. 

• Hairs are divisible into two primary groups, long and short ; but 
each of these groups admits of division into two sub-groups, namely, 

1. Long and soft hairs, of which the hairs of the head are the type ; 

2. Long and stiff" hairs, which include the hair of the beard, whiskers, 
pubes, and axilla; 3. Short and stiff* hairs, such as those of the eye- 
brows, the eyelashes, the vibrissas nasi, and the hairs of the meatus 
auditorius ; and, 4. Short and fine hairs, including the downy hairs 
(lanugo), and those of the caruncula lachrymalis. 

The hairs of the head offer much variety in point of size. For 
example: in 2000 hairs taken from 38 persons, the finest ranged 
between , J (MI and ,,,',,, of an inch; the former of these occurring in 
three instances, one in black, the others in brown hair, the subjects of 
the observations being adult men ; the latter in seven persons, two 
men with black hair, and five women, four with brown and one with 
chestnut hair. The coarsest hairs in the same heads ranged between 
, ',,,'Hiid i \r> °f an i ncn , the former being the flaxen hair of a female 
child, and the latter, a brown hair from the head of a female adult. 
In three South American Indians, a man, a young woman, and a 
child, the finest hair occurred in the child (y^n of an inch), next in 
the man ( 5( ' )0 ), and lastly in the woman (455). The coarsest hairs of 



FORM AND SIZE OF HAIRS. 55 

the same individuals were 5 |^ of an inch in the man and woman, and 
5 |u in the child. The color of the hair in the two former was black, 
and that of the child red. In a New Zealand chief, the finest of fifty 
hairs measured ? i„, and the coarsest 2 ^ of an inch. The influence 
of a morbid habit on the hair is shown in the instance of a scrofulous 
female child ; of ninety-seven of the flaxen hairs of this child, the 
finest measured j^q, and the coarsest ^J^ of an inch. For conve- 
nience of reference I have arranged these measurements in a tabular 
form, as follows : 



Number of hairs 
examined. 



Finest. Coarsest. 



British, 200(31 ... T ^to^ ... ^ to T ! T 

South Americari Indians, . . 155 ... joVo" t0 To"<? ••• uilT to 'zi'U 



New Zealander, ... 50 



~Z~51S ■ ■ • "SFff 



Scrofulous child, . . . 97 TT5<T •'• ?io 

The average thickness of the 2000 hairs above examined ranged 
between gi^ of an inch, the flaxen hair of a female child, and ji^ of 
an inch, the brown hair of an adult woman. The average thickness 
of the hairs of the three South American Indians was ^^ of an inch 
in the child, gi^ in the woman, and g 1 ^ in the man. The average 
measurement of the hair of the New Zealand chief was ^i^, and that 
of the scrofulous child, gi^ of an inch. In a tabular form, these 
measurements would stand as follows : 

British, Tsh to nh 

South American Indian, ....... jitf t0 3l>"o 

New Zealander, . . . . . . . . . j^ 

Scrofulous child, ......... -^fa 

The average dimension in thickness of human hair, according to 
the above table, is ^ v of an inch. Leeuwenhoeck and Rosenmuller 
state it to be g ^ of a Paris inch, 2 which is certainly too little; while 
Weber approaches more nearly to the measurements given above, as 
may be seen by the following table : 

His own hair, -^ to T f^ Paris inch. 

Mlllatt °. *l<T t0 ?H 

Senegatribian negro, woolly, ..... xtx t0 ¥F3~ " 

Nubian negress, ^ to ^ 

Rosenmuller' s table is as follows : 

Adult > vfo to jfo Paris inch. 

? b . ild ' v • . ■ cc Tktoyto 

Lanugo from body of fostus, T8X5T5 

It is probable that these writers deduce their average from extremes 
of measurement, a proceeding that must necessarily lead to error. A 
correct average can only be obtained by ascertaining the medium 
range, and deducing the average from that range. 

With respect to the influence of age and sex upon the thickness of 
the hair, my observations are in favor of the coarsest hair being found 

1 The measurements were in all cases made as close to the head as possible, to avoid 
the influence of stretching and wear. 

2 A Paris incli is ^j longer than an English inch. 



56 ANATOMY OF THE SKIN. 

in the female, and the finest in the male ; and of the hair of children 
being finer than that of the adult, thus : 





Number of beads. 


Number of hairs. 


Range of thickn 


Child, 
Man, 


6 
18 


269 
1016 


o o 7 to ¥77 
777 to 3 is 


Woman, . 


IS 


940 


777 t0 277 



This is the reverse of what might have been anticipated ; I should 
certainly have looked for a coarser hair in the male than in the 
female, for, independently of sex, the habit of cutting the hair closely 
might have been expected to conduce to its greater strength. Indeed, 
in one of the cases examined, the head had been repeatedly shaven 
with a view to render the growth of the hair strong, but the hair did 
not exceed the medium average of size. 

The variety in the thickness of the hairs of the same head is very 
considerable, as may be perceived in the following instances, taken 
without selection from a number of observations : 

Coarsest. Medium range. Average. 

?io ••• 777 to 777 ••• ih 
777 ■ ■ ■ 5Tff t0 777 • ■ ■ ¥77 

577 • ■ • 777 t0 T77 • • • 470 

270 • • • 377 t0 377 • ■ • ¥77 
7T7 • • • 577 t0 2T0 • • • 577 



Vumber of hairs. 


Finest. 


67 


T775 


81 


T770 


79 


T277 


97 


777 


57 


1 

777 


64 


777 



th 



¥70 



The "medium range" in this table includes the measurements 
within which the greatest number of hairs are found, and from it the 
average is deduced. 

Variety in thickness is not, however, confined to the different hairs 
of a single head ; it is met with even in an individual hair. Thus, a 
hair six inches long, and apparently of uniform dimensions, ranged 

t various points of its length ; 
; while a white hair, which was 
obviously enlarged at short distances, presented a range of 7 ^ to 2 go» 
the diameter of its point measuring ■§ ^q of an inch. The short hairs 
of the body not unfrequently exhibit an appearance which may be 
termed varicose. In the instance of the long hairs of the head a 
small share of the difference of diameter may be referred to over- 
stretching in dressing the hair, but this cause cannot apply in the 
case of the varicose hairs. It has been shown by experiment that 
hair is so elastic that nothing but inordinate stretching could occasion 
the permanent constrictions to which my admeasurements refer. 
Weber found a hair ten inches long to stretch to thirteen inches, and 
a hair stretched one-fifth returned to within one-seventeenth of its 
original length. 

With respect to color as a condition associated with diversity in 
thickness, my observations tend to show that flaxen is the finest, and 
black the coarsest hair. Gray hairs commonly represent in thickness 
the color which they succeed ; but as a general rule, the white hairs 
which intrude themselves as age advances, are coarser than the hairs 
among which they are found, suggesting the inference, that deficiency 
of pigmentary is compensated by excess of albuminous principle. 



DIMENSIONS OF HAIRS. 57 

The most extensive range in thickness is enjoyed by light brown 
hair. The average measurements of hairs of different colors are as 
follow : 

Flaxen, -t+tt to -A-* of an inch. 



Chestnut, ?rk t0 si 



Red, 



h t0 rsT> 
h t0 sh 



¥"0~0 
3"0 0" 



, chestnut. Man, black. 


Man, brown. 


Woman, brown 


ST5 


• • JSS • • 


¥00" • • 


?h 


2TT0" 


2lb 


— ■ • 


— 


¥To" 

3 00 


• • Y7o • • 


30 ' • 


Tib 


sh 


• • 377 • • 


To o • • 


Too 


• • 20(7 • • 


— • • 


— 


T57 


• • -To • • 

• • TiTo • • 


— '. '. 


3^0 


— 


• • ToTT • • 


— 





50~ff 


• • T5<> • • 


— • • 





T^TT 





— • • 









Dark brown, 

Light brown, . . . . . . ^ to ^ 

White ?h io ?io 

Black, wo to 3i(y 

These observations accord with those of Whithof. 

The hairs of different regions of the body of the same individual 
necessarily present some degree of variety of diameter ; but the amount 
of variation is less than might have been anticipated, as may be seen 
by the following table, in which the average term is employed. The 
diameter of the hair of the head is given in the first line as a standard 
of comparison. 

Head, . 

Beard, . 

Eyebrow, 

Pubes, 

Breast, 

Whiskers, 

Eyelashes, . 

Axilla, 

Thigh, 

Leg, . 

Vibrissse auris, 

Upon the greater part of the body the hairs are very minute (downy 
hairs, lanugo), and in many situations are not apparent above the level 
of the skin ; in others, as upon the outer sides of the limbs, they attain 
a certain length ; and, upon the head, face, pubes, perinseum, axillae, 
and around the nipple, their length is considerable. When left to its 
full growth, as it is in the female, the hair of the head attains a length 
of from twenty inches to a yard, the latter being regarded as unusually 
long ; but in an instance that lately came under my notice, the hair 
measured six feet. The hair is known, besides, to constitute a sexual 
character, appearing for the first time on certain parts of the body at 
the period of puberty, and occurring on regions of the hodj of the 
male where it is generally imperceptible in the female, as upon the 
sides of the face, the chin, the breast, the shoulders, and the abdomen. 

The free extremity or point of a hair is conical, and more or less 
sharp. When examined in one of the minute or downy hairs which 
has not risen above the level of the surface, the point appears obtuse, 
on account of its little difference in diameter from that of the shaft 
(Plate III., fig. 18). In the short hairs of the body and on the head, 
on the other hand, the point is apparently sharper, from the greater 
relative size of the shaft, and actually so as a consequence of dessica- 
tion. The pointed character of a hair is very perceptible in the eye- 
brows and eyelashes, as also in the vibrissas of the nose and meatus 
auditorius. When the hair has been cut, its pointed character is neces- 
sarily lost. Sometimes, however, there is an appearance of pointing, 



58 ANATOMY OF THE SKIN. 

the combined result of attrition and dessication. But the more usual 
character, when the hair has been long neglected, is a splitting of the 
end into two or three filaments. 

The root of a hair, or that part which is included within the skin, 
inclosed in the hair-sac or follicle, is somewhat greater in diameter 
than the rest of the shaft, in consequence of being nearer the source 
of the nutritive fluids, and protected from evaporation: and for the 
same reasons it is cylindrical in form, while at its lower part the root 
expands into an oval-shaped mass, the bulb, which occupies the whole 
breadth of the follicle, and is implanted on a small elongated papilla, 
derived from the fundus of the follicle, the papilla of the hair. When 
a hair is cast, no trace of the bulb is perceptible, because the soft cells 
of which it is composed are dried up, and only those cells remain which 
have undergone transformation into the horny fibres of the hair. In 
this state the root of the hair is pointed, and resembles an old paint- 
brush worn to a conical stump (Plate III., fig. 18). But when it is torn 
out by force, it presents a variety 1 of appearances, depending on the 
removal with it of more or less of the epidermal lining of the follicle, 
the root-sheath. Sometimes this follicular root-sheath is collected in 
a mass at the extremity of the hair, and the latter appears, in conse- 
quence, to be bulbous. Sometimes the epidermal sheath is drawn to 
a greater or less extent beyond the root, and then, according as it is 
straight or curved in direction, the root has the appearance of being 
pointed or uncinated. 

In structure, a hair is composed of three different modifications of 
tissue (Plate IV., fig. 3), namely, a loose cellulated tissue, which occu- 
pies its centre, and constitutes the medulla or pith ; a fibrous tissue, 
which incloses the preceding, and forms the chief bulk of human hair ; 
and a thin layer, the so-called cuticle, which envelops the fibrous 
structure, and forms the smooth external surface of the hair. 

The medulla is absent in the minute or downy hairs, and is not un- 
frequently absent or small in quantity in fine hairs, from whatever 
region they are selected. In the coarser hairs of the head and body, 
on the other hand, it is always present, and is especially remarkable 
in white hair. It varies in breadth from a mere line to a cylindrical 
body of one-third the diameter of the hair (fig. E), and is composed of 
large nucleated cells, of a globular or oval figure, filled with 
granules, and packed together, apparently without order. 
When newly formed, these cells, with their granules, are 
distended with fluid, but in the shaft of the hair the cells 
frequently contain air, which, from its highly refractive 
powers, gives the medulla a dark appearance when examined 
with the microscope. Varieties in structure of the hair are 
unusual ; I have, however, once observed the presence of 
two medullae. The displacement of the medulla nearer to 
one side of the periphery of the hair than to the other, in 
the short and thick hairs of the body, is not uncommon. 

The middle or fibrous layer of the hair is composed of oval-shaped 
cells, closely packed together, and arranged in a linear order. These 
cells are identical in structure with the cells of the deep stratum of the 






STRUCTURE OF HAIRS. 59 

epidermis, that is to say, they are composed of granules congregated 
around a central granule which constitutes the nucleus of the cell. 
When examined with the microscope, it is not in all cases easy to dis- 
cover the cells, but their component granules are always obvious, and 
from the plan of disposition of the cells, and their oblong shape, the 
granules have a linear arrangement, and assume the character of fibres. 
The hair-fibres offer some variety of appearance, according to the focus 
in which they are viewed. For example, with a superficial focus, the 
peripheral granules are alone seen, and the hair appears to be entirely 
composed of granules arranged in single rows. With a deeper focus, 
the rows of granules appear to be associated in pairs, each pair having 
between them an unconnected row of dark and apparently nuclear 
granules. In this view the fibres resemble very closely a chain com- 
posed of open links. While, with a still deeper focus, the centre of the 
cell, with its nucleus and granular periphery, is brought into view. 
In different hairs these three appearances are seen with various degrees 
of distinctness. 

The color of hair appears to reside partly in the granules and partly 
in an intergranular pigmentary substance which occupies the inter- 
stices of the granules and of the fibres. The most deeply-colored 
granules are those which constitute the nuclei of the cells, and in the 
lighter hairs these alone give color to the fibrous structure. In the 
darker hairs more or less of the peripheral granules are also colored, 
and pigment may be observed in greater or less abundance in the 
interfibrous spaces. With respect to the granules, the pigment ap- 
pears to occupy their periphery, sometimes surrounding them com- 
pletely, and sometimes occupying a portion only of their surface. In 
the peripheral granules of the cells, the outer segment is the more 
frequent seat of the pigment, while many are entirely destitute of that 
element. This total absence of color, in many of the granules com- 
posing even the blackest hair, gives to the fibrous structure, when 
examined with the microscope, an interruptedly streaked appearance 
(Plate IV., fig. 2) ; and the irregular intermixture of pigment granules 
with colorless granules, bestows upon the tissue between the streaks 
a dotted character. In red hair the granules have a delicate golden 
yellow tint, while the pigmentary matter is amber-colored. In the 
white hair of Albinoes and of the aged, the pigment is wanting. 

The external layer or cuticle of the hair is a thin and transparent 
envelope, measuring in the hairs of the head about g^^ of 
an inch in thickness. It is transparent and homogeneous, 
but is marked externally by undulating and jagged lines, 
which represent the edges of quadrangular non-nucleated 
scales or plates, which overlap each other from the root to 
the point of the hair. The overlapping border of the 
Bcale is notched and convex, and forms a slight projection 
beyond the level of the surface. Seen with the microscope, 
. the prominent edges of the scales have the appearance of 
undulating and jagged lines, which cross at right angles 
the shaft of the hair (Fig. F). The prominence of the edges of the 
superficial scales of a hair is the cause of the sensation of roughness 




60 ANATOMY OF THE SKIN. 

which we experience in drawing a hair between the fingers from the 
point towards the root, a sensation which is not perceived when the 
direction of the hair is reversed. It explains, also, the circumstance of 
hairs occasionally working their way into wounds, beneath the nails, 
and into the gums. In the hairs of the axillae the external layer is gene- 
rally more or less split up into fibres, which give it a shaggy appear- 
ance. Sometimes this appearance occurs only on one side of the hair, 
or more on one side than the other, while at others it is equally con- 
spicuous around the entire shaft. It forms a remarkable distinctive 
character of the hairs of this region, and is due, as I believe, not to 
original formation, but to their saturation with the perspiratory fluid 
and the breaking up of the scales of the cuticle by softening and con- 
stant attrition. In the neighborhood of the bulb, the two portions of 
the cuticle of the hair, now described, namely, the outer scale-formed 
layer and the inner transparent layer, are distinguishable from each 
other as separate structures, and are peculiarly interesting, from illus- 
trating the homology of hairs and teeth ; the transparent part of the 
cuticle of the hair being, according to Huxley, homologous with the 
enamel of a tooth; and the squamous layer, which is essentially the 
basement membrane of the papilla of the hair, with the corresponding 
membrane of the pulp of a tooth, and described by Nasmyth under 
the name of "persistent capsule." 

The hairs are implanted at a variable depth within the skin, and are 
maintained in their position by means of their follicles. The depth 
of implantation of the hairs of the head is between 1 1 n and fa of an 
inch, their bulbs being situated in the deep stratum of the corium, 
and frequently extending into the subcutaneous adipose tissue. The 
hairs of the whiskers, beard, and pubes, are commonly prolonged 
beyond the corium, while those of -the general surface rarely exceed 
its mid-depth. The depth of implantation of the hair of the pubes is 
the same as that of the hairs of the head. 

The follicle of the hair, or hair-sac, is a tubular canal excavated in 
the substance of the derma and lined by a thick layer of epidermis. 
It consequently presents the same structures that enter into the com- 
position of the skin, namely, an epidermal lining or sheath, commonly 
called the root-sheath from its intimate relation with the root of the 
hair ; the basement membrane of the corium, known as the structure- 
less membrane of the hair-sac ; and two fibrous layers, one consist- 
ing of fibres with transversely arranged columnar nuclei (Kolliker's 
layer) ; and an exterior membrane, consisting of longitudinal fibres 
and nuclei, into which the muscles of the hair-sacs, the arrectores 
pilorum, are inserted. This latter layer also contains a plexus of 
bloodvessels, together with the filaments of nerves, and supplies the 
means of nutrition to the root-sheath and its contained hair. The 
epidermal layer or root-sheath is composed of several strata of cells, 
which, having each a different arrangement, are regarded as distinct 
membranes; the most external of these, corresponding with the rete 
mucosum of the epidermis, presents a stratum of cells of which the 
long axis is transverse; this is the outer root-sheath; next follows a 
stratum, of which the cells have a longitudinal arrangement and have 



STRUCTURE OF THE HAIR-FOLLICLE. 61 

no nuclei, this is the inner root-sheath of Henle ; while, lining the 
latter, is a third layer, composed of cells with nuclei also arranged 
longitudinally (Huxley's layer). 1 The epidermal layer is nearly as 
thick as and often thicker than the hair which it incloses, and lies in 
close contact with the latter to the fundus of the sac and base of the 
papilla pili. 

The hair-follicle or hair-sac terminates inferiorly in a slightly dilated 
coecal pouch, and from the centre of the fundus of this pouch there 
projects into its cavity a dermal papilla of an ovate form, the broad 
end of the papilla being free, and the smaller end continuous with the 
substance of the derma external to the sac. This is the papilla of the 
hair, the hair-pulp, or hair-germ, or blastema pili ; it is identical in 
structure with an ordinary dermal papilla, only differing in size, in 
form, in position, and in the absence of capillary vessels. The hair- 
papilla measures between J and J„ of a line in length, by ^j to ^ °f 
a line in breadth ; 2 and is surrounded by the elements of the future 
hair, which are round nucleated cells, more or less charged with pig- 
ment, and about 4 ^ ^ or ^ J^ _ f an inch in diameter. As these cells 
are traced higher into the root of the hair, they become elongated and 
gradually metamorphosed into the permanent structures of the hair, 
the fibrous cortex and the still cellular medulla. The researches of 
Mr. Huxley have tended to establish an identity of nature and design, 
in other words, an homology between the hair and a tooth ; and to 
prove that as a tooth is a product of the corium of the mucous mem- 
brane, so also is a hair the product of the corium of the skin ; and 
that as the pulp of the tooth is metamorphosed into ivory, so the 
papilla or pulp of the hair-bulb is metamorphosed into the fibrous 
cortex of the hair — the cuticle of the hair representing the enamel of 
the tooth, and the medulla of the hair the cavitas pulpse. 3 

Growth of the hair is accomplished by the successive formation of 
new cells in the superficial portion of the papilla of the hair, and these 
cells are gradually moved onwards and converted into the fibrous 
tissue of the hair, while new cells are produced to supply their place. 
As this metamorphosis takes place, the cells in course of conversion 
into the fibres of the hair become elongated, while their lateral diame- 
ter is correspondingly reduced, and the newly-formed root of the hair 
is consequently smaller than the bulb. Probably the fluids of the 
metamorphosed cells are transmitted onwards into the shaft of the 
hair, and so tend to its nutrition and health. The energy of growth 
of the hair offers considerable diversity ; it is more active in youth 
than in age, in summer than in winter, in hair which is cut than in 
that which is left to its natural growth, and in hair that is frequently 
cut than in that which is cut but seldom. In a young person of feeble 
constitution recently shaved, I found the hair of the head to have 
grown four lines in three weeks, showing that the amount of growth 
is probably more than a line in the course of the week. Berthold' 

1 Kollilcer's Manual of Human Histology, vol. ii. 2 Kolliker. 

8 On the Development of the Teeth and on the Nature and Import of Nasniyth's 
Persistent Capsule. Microscopical Journal, vol. i., 1853, p. 149. 
4 Miiller's Archiv. 1800. 



62 ANATOMY OF THE SKIN. 

ascertained that in young females between the age of sixteen and 
twenty-four, the growth was seven lines in the month. He also 
showed by his observations that the hair grew the quicker for being 
frequently cut; that the beard shaved every twelve hours grew at the 
rate of five inches and a half to one foot in the course of a year ; that 
when shaved every twenty-four hours, it grew at the rate of five to 
seven inches and a half; and that shaved every thirty-six hours, it 
grew only four to six inches and a half during the same space of time. 
He also found that the hair grows one-sixteenth faster by day than 
by night, and more quickly in the summer than the winter time. 
Whithof calculated that the hair of the beard grows at the rate of one 
line and a half in the week; equivalent to six inches and a half in the 
course of a year, or twenty-seven feet in a lifetime of eighty years. 
And Eble informs us that in the Princes' court at Eidam, there is a 
full length painting of a carpenter whose beard was nine feet long. 

It is by no means uncommon to find two hairs, and sometimes 
three, issuing from the aperture of one follicle ; but at a short distance 
below the level of the epidermis, such a follicle would be found to 
divide into separate tubules for each hair. Within the nose I have 
counted as many as ten hairs issuing in this manner from a common 
follicle, but below the surface there were always as many tubules as 
hairs. 

In a healthy state of the skin the space between the epidermal 
lining of the follicle and the hair is very trifling. Indeed, it is 
merely sufficient to receive the exfoliated scales of the former, which 
are to be conveyed with the growing hair to the exterior. At a short 
distance (about half a line from the surface) within the derma, how- 
ever, the space enlarges, in consequence of the junction with the 
follicle of one, two, or more excretory ducts of sebiparous glands, 
and the consequent stream of sebaceous substance which is poured 
into it. It is in this part that the entozoa of the hair follicles are 
chiefly found. 

Mandl entertains some peculiar views with regard to the structure 
and mode of growth of hair. He describes a hair as consisting of 
a cortical portion, which is cellular, and a medullary portion, wdiich 
is tubular. Through the latter, he conceives that the fluids of the 
hair ascend, and are deposited at the free extremity of its shaft, in 
successive layers, each layer becoming gradually smaller in diameter, 
until the hair eventually assumes the form of a fine point. This 
structure, he says, is indicated on the tapering extremity of a hair by 
a series of annular lines. The mode of growth here described he 
believes to be proved by the production of a pointed end upon hairs 
which have been cut, and also by the whitening of hair which some- 
times commences at the point. The latter fact he explains by the 
transmission of colorless fluids to the end of the hair. Besides this 
mode of increase, he admits that another takes place at the root by 
apposition. I have convinced myself that Mandl is in error with 
regard to this hypothesis. Growth never takes place at the point of 
the hair, and, consequently, the hair cannot grow white at the point. 
It may exhibit indications of bleaching in that situation, from external 



DIRECTION OF THE HAIR. bd 

conditions sooner than in the rest of the shaft, but the process is 
purely physical. Again, the annular lines to which this author refers 
are simpty the margins of the overlapping scales of the cuticle of the 
hair, the scales being smaller and less jagged in that situation than on 
the shaft of the hair. 

The hair-follicles are not situated perpendicularly, but obliquely in 
the skin, hence the direction of the hairs, after their escape from the 
follicles is in the same sense inclined towards the surface; and the 
" set" of the hair, from the root to the point, is governed by a law as 
precise as that which regulates any other of the secondary vital func- 
tions. Thus, on the head, the hair radiates from a single point, the 
crown, 1 to every part of the circumference, making a gentle sweep 
behind, towards the left, and in front, to the right. The direction of 
this sweep is naturally indicated on the heads of children, and is that 
in which the hair is habitually turned. On the forehead the downy 
hairs proceed from the middle vertical line, with a gentle curve to the 
right and left, sweeping downwards to the situation of the whisker, 
and forming, by their lower border, the upper half of the eyebrow. 
Occasionally, the line of divergence of the forehead is oblique in its 
direction, running from the left of the forehead to the root of the 
nose. At the inner angle of each eye is situated another radiating 
centre, like that of the crown of the head ; and a vertical line of 
divergence is continued downwards from this point, by the side of the 
nose, mouth, and chin, to the under part of the latter, where it curves 
inwards to the middle line. The upper and inner rays from this 
centre ascend to the line, between the eyebrows, where they meet 
those which are proceeding from the opposite centre, and those, also, 
which are diverging from the vertical central line of the forehead ; so 
that here a lozenge is formed, which is the point of approximation of 
hairs from four different quarters. It is this circumstance that gives 
to the hairs of the inner end of the eyebrows a direction towards the 
middle line; and occasionally we see instances in which, from the 
unusual development of these hairs, the eyebrows meet at the base of 
the forehead, and form a little crest, for a short distance, along the 
root of the nose. The lower and inner rays from the angle of the 
eye diverge from the preceding, and are directed downwards and 
inwards upon the side of the nose ; when strongly developed, they 
meet those of the opposite side on the ridge of the nose, and at their 
point of divergence from the ascending current necessarily form an- 
other lozenge. This latter is a lozenge of divergence, that of the 
forehead being one of convergence. The upper and outer rays from 
the angle of the eye curve along the upper lid, forming, by their upper 
margin, the lower half of the eyebrow, and at the outer angle of the 
eye being lost in the converging currents of the whisker. The lower 
and outer rays from the centre at the angle of the eye, together with 
those from the vertical line of the side of the nose, mouth, and chin, 

1 Sometimes there are two crowns, as in a little girl now before me, in whom the 
sweep from the left crown is to the left, ami the tight to the right, so that the hairs from 
the two crowns converge and meet in a crest along the middle line of the head. 



64 ANATOMY OF THE SKIN. 

make a gentle sweep over the cheek, side of the face, and jaw, to be 
lost, the upper ones in the front of the whisker, the middle rays, after 
passing beneath the ear, in the middle line of the back of the neck, 
and the lowest rays in the angle or bend of the jaw, in which latter 
situation they come into opposition with an ascending current from 
the chest. The rays from the inner margin of the vertical line of the 
side of the nose, mouth, and chin, are directed inwards upon those 
parts. On the upper lip they are met by a current directed from the 
apertures of the nose, outwards, and forming the sweep of the musta- 
chio; a similar disposition is observed in the middle line of the lower 
lip, near its free edge, while the beard is formed by the convergence 
of two side currents meeting at the middle line. The current from 
the side of the head divides at the ear, those which pass in front of 
that part, and some, also, from the skin before the ear, contributing 
to form the posterior border of the whisker, and then passing back- 
wards beneath the ear, with the current from the face, to the middle 
line of the nape; while those which pass down behind the ear con- 
verge with those from the back of the head also to the middle line of 
the nape. 

On the trunk of the body there is a centre of radiation from each 
armpit, and two lines of divergence, one of the latter proceeding hori- 
zontally to the middle of the front of the chest, the other from this 
horizontal line, just in front of the axilla, vertically along the side of 
the trunk, across the front of the hip, and down the inner side of the 
thigh to the bend of the knee. From the axillary centre, and from the 
upper side of the horizontal line, a broad and curved current sweeps 
upwards and inwards over the upper part of the front of the chest, and 
outwards, around the neck to the middle line of the nape, the outer- 
most part of the current passing over the shoulder to the middle line 
of the back. From the lower side of the horizontal line, and from the 
front of the upper half of the vertical line of the trunk, the set of the 
current is downwards and inwards, with a gentle undulation to the 
middle line, and from the lower half of the vertical line of the trunk, 
the direction is upwards towards the middle line and umbilicus, so 
that the latter is the centre of convergence of four streams from the 
anterior aspect of the abdomen, two from above and two from below. 
From the centre, at the axilla and posterior border of the vertical line 
of the trunk, the current streams downwards and backwards, also with 
an easy undulation, to the middle line of the back. The inner ex- 
tremity of the horizontal line of the chest is the seat of a lozenge of 
divergence, and that of the line of the bend of the lower jaw, at the 
front of the neck, of a second. 

From the axillary centre just described there proceeds another line 
of divergence, which encircles the arm like a bracelet, immediately 
below the shoulder. From the upper margin of this line the direction 
of the current is upwards over the shoulder, and then backwards to 
the mid-line of the back. Another line commences at this ring on the 
front part of the arm, and runs in a pretty straight course to the cleft 
between the index finger and thumb on the back of the hand : this is 
the line of divergence of the arm; from it and from the ring the stream 



DEVELOPMENT OF HAIR. 65 

sets, at first, with a sweep forwards, and then with a sweep backwards 
to the point of the elbow. In the forearm the diverging currents 
sweep downwards in front, and upwards behind, also tending to the 
point of the elbow, which is thus a centre of convergence ; while on the 
back of the hand and fingers the sweep outwards, with a curve having 
the concavity upwards, is quite obvious. 

On the lower limb there are two vertical lines of divergence ; the 
one being the continuation of that of the side of the trunk, proceeding 
around the inner side of the thigh to the bend of the knee ; the other, 
an undulating line, beginning at about the middle of the hip, running 
down the outer side of the thigh to the bend of the knee, then con- 
tinuing down the outer side of the leg, reaching the front of the ankle, 
and terminating on the foot at the cleft between the great and second 
toe. A short oblique line connects the two vertical lines at the bend' 
of the knee. On the front of the thigh the streams from the two lines 
converge, and descend towards the knee. On the back they converge 
also at the middle line, but ascend towards the trunk of the body. 
On the leg, where there is but one line, the diverging currents sweep 
around the limb, and meet upon the shin, while on the foot they 
diverge with a sweep as upon the back of the hand. 

Quantity of hair has reference to the proximity of the follicles, and 
also to the number of follicles which open by one common aperture 
on the skin. Whithof counted the number of hairs on a square inch 
of skin, and found of black, 588 ; chestnut, 648 ; and flaxen, 728. A 
similar investigation was made by Jahn in the person of an unusually 
hairy man, twenty-eight years of age. In a given extent of skin in 
this person he found on the 

Summit of the head, . . . . .321 hairs. 

Back of the head, 242 " 

Front of the head, 238 " 

Chin, 52 " 

Pubes, 45 " 

Forearm, . . . . . . . . 31 " 

Outer border of hand, 20 " 

Front of thigh, 21 " 

In four years after this calculation was made, the man having 
married in the meantime, the number Avas diminished on all parts of 
the body, with the exception of the chin and pubes, where they had 
increased, on the former seven, and on the latter five. 

In my own observations directed to this point, I ascertained that 
the number of hair- pores in the scalp of a man twenty-five years of 
age, having black hair, amounted in the square inch to 744. Now, 
supposing eacli pore to give passage to a single hair only, this number 
would represent the amount of hairs growing on a superficial square 
inch of the skin of the head ; and, as the extent of surface of the scalp 
is about one hundred and twenty superficial square inches, the number 
of hairs on the entire head would amount to 89,280, or in round 
numbers to 90,000. This calculation, however, has reference only to 
a thin head of hair, for many of the pores give passage to two hairs ; 
and, supposing this to be the case with one-half, we should then have 
as the number of hairs in a superficial square inch, 1116 ; and upon 

5 



66 ANATOMY OF THE SKIX. 

the entire head 133,920. Or, supposing, as would probably be the 
case, in a thick head of hair, that every pore gave forth two hairs, 
the number in an inch would then be increased to 1488, and the total 
number for the whole head to 178,560 ; nearly two hundred thousand. 
As an average, therefore, of the number of the hairs of the head, I 
think we may fairly take the number in a superficial square inch at 
1000, which would give us the number on the entire head 120,000. 

Looking back on the structure of the hair, we cannot but be forcibly 
impressed with the perfection of organization which it exhibits ; and 
this feeling is increased when we reflect on the elasticity and strength 
of so delicate and slender a thread. The former of these properties, 
tested by the experiments of Weber, has been referred to at page 56. 
. A single hair of a boy eight years of age, says Robinson, in his 
"Essays on Natural Economy," supported a weight of 7812 grains; 
one of a man, aged twenty-two, 14,285 grains ; and the hair of a man of 
fifty-seven, 22,222 grains. Muschenbroeck found that a human hair 
fifty-seven times thicker than a silkworm's thread would support a 
weight of 2069 grains, and a horsehair, seven times thicker, 7970 
grains. The strength of the hair is due to its fibrous portion, for 
hairs deficient in this structure, like those of the fallow deer, are 
remarkable for their brittleness. 

The development of hair has been made the subject of research by 
Heusinger, Simon, 1 and other physiologists. The earliest trace of 
the hair rudiments is perceptible at the twelfth week of embryonic 
life, and of the hair itself at the eighteenth week. These early traces 
are found in the eyebrow, and are followed successively by similar 
appearances on the head, back, chest, and extremities, so that by the 
end of the sixth month hair may be met with on the whole body, 
with the exception of the hands and parts of the forearm and leg. 
Development of the hair commences by the formation of small globular 
masses, resembling buds, on the under surface of the rete mucosum. 
These buds grow inwards into the corium, and after a time have the 
appearance of flasks, composed of nucleated cells, identical in struc- 
ture with those of the rete mucosum. Subsequently the central cells 
become elongated in form, darker colored than the peripheral cells, 
and separate from the latter ; and at a still Later period, the central 
cells are metamorphosed into a hair and inner root-sheath, while the 
external cells become transverse in their position, and are converted 
into the outer root-sheath, around which are developed the three 
membranes of the hair-sac. It follows, therefore, that the primitive 
hair does not grow, as in its subsequent existence, but is developed, 
in all its completeness, with a point, a shaft, and a bulb, and that at 
the same time with the growth inwards of the flask-shaped process of 
the rete mucosum, a papilla is developed from the corium, and grows 
outwards to penetrate its fundus, and develop the first trace of the 
future hair. Two movements of growth are therefore established — a 
growth inwards of the hair rudiment, and a growth outwards of the 

1 Zur Entwiekelungsgesclrichte iler Haare. Von Dr. Gustav Simon. Miiller's Archiv., 
1841. 






SHEDDING AND REPRODUCTION OE THE HAIR. 67 

papilla and hair. The point of the hair is in this way brought to the 
surface of the epidermis, and bursting through the cone of the inner 
root-sheath, is developed as a free hair. Simon has described the 
young hair as being bent upon itself, so that the point and the bulb 
are approximated, and the young hair as making its way through 
the aperture of the follicle in the form of a loop. 

In the human embryo, the lanugo infantium begins, therefore, to 
be apparent during the first half of the fifth month of intra-uterine 
existence, upon the eyebrows, upper lip, and around the mouth ; and 
at about the middle of the month upon the head. By the end of the 
sixth month it is pretty general over the whole body, the last parts 
on which it is seen being the backs of the toes and fingers, the ear, 
and the nose. At the sixth month Eble found the hairs of the head 
to measure three lines, those of the eyebrows two lines, and the eye- 
lashes half a line. At birth the foetus is covered with a thick down, 
the minute hairs being pale, and without color, and in their structure 
consisting only of cortical substance and cuticle. It is at this period 
that we have the best opportunity of observing the direction of the 
hairs; for during the first year the greater part of these temporary 
hairs have been shed, and they are succeeded by a more permanent 
kind, which appear upon the surface only in certain situations. At 
the period of adolescence the hairs acquire a new impulse of growth 
in co-relation with the more active development of the frame ; and 
when the powers of the system are on the wane, the hair is among the 
first of the organs of the body to evince an associated infirmity. 

The process of shedding and renewal of the hair has been observed 
by Kolliker in the eyelashes of a child a year old, and has since been 
seen in operation in other regions of the body. It is simply a repe- 
tition of the phenomena of development of the hair already described, 
but taking place from the fundus of a hair-sac instead of from the 
surface. The cells of the root-sheath protrude, and form a bud, and 
the bud gradually elongates in the deeper layers of the corium, carry- 
ing with it the hair-sac, and having inclosed in its mass a hair papilla. 
On attaining a certain length, the central and peripheral cells assume 
a difference of character — the former acquiring pigment and a longi- 
tudinal prolongation; die latter remaining clear, and becoming trans- 
verse; the former undergoing metamorphosis into hair and inner 
root-sheath, the latter into outer root-sheath. Subsequently, growth 
outwards begins to be active ; the old hair is moved onwards to the 
surface, and ejected through the aperture of the follicle ; while the 
new hair bursts its enveloping sheath, and takes the place of its pre- 
decessor. By this mode the downy hair of the infant, the lanugo 
infantium, is replaced by the permanent hair by which it is succeeded; 
but it is doubtful whether this process of renewal is continued after 
the period of infancy. It is obvious that it may occur, and may be 
one mode of reproduction of the hair; while, on the other hand, it is 
known that the common mode of reproduction of the hair, when a 
hair has fallen or been removed by violence, is the regeneration of 
the original papilla, or the restoration of its normal functions. 

In chemical composition hair is found to differ from epidermis and 



68 ANATOMY OF THE SKIN. 

horn, and also from albumen and fibrin. Its chief constituents are an 
animal substance, a modification of protein, apparently a compound of 
protein and sulphur, a certain quantity of fat, some pigment, and 
certain mineral and earthy salts, among which are iron, manganese, and 
silica — the quantity of ash varying between one and two per cent. 

According to the analysis of Vauqjtielin, the chemical constituents 
of hair are — animal matter, in considerable proportion ; a greenish 
black oil ; a white, concrete oil, in small quantity ; phosphate of lime ; 
carbonate of lime, a trace ; oxide of manganese ; iron ; sulphur, and 
silex. Red hair contains a reddish oil, a large proportion of sulphur, 
and a small quantity of iron. White hair, again, exhibits a white oil, 
with phosphate of magnesia. The white hair of old persons contains 
a maximum proportion of phosphate of lime. 

The ultimate analysis of hair, according to Scherer, 1 exhibits the 
principal elementary constituents in the following proportions: 

Carbon, 50.652 

Hydrogen, 6.769 

Nitrogen, 17.936 

?7f"' \ 24.643 

sulphur, / 

Fair hair contains the least carbon and hydrogen, and most oxygen 
and sulphur; black hair follows next; while brown hair gives the 
largest proportion of carbon, with somewhat less hydrogen than black 
hair, and the smallest quantity of oxygen and sulphur. The hair of 
the beard was found to contain more carbon and hydrogen than the 
hair of the head, and less oxygen and sulphur. The quantity of 
nitrogen is the same in all. 

NAILS. 

The nails are horny appendages of the skin, identical in formation 
with the epidermis, but peculiar in their mode of growth. A nail is 
convex on its external surface, concave within, and implanted by 
means of a root into a fold of the derma (vallecula unguis), which is 
nearly two lines in depth, and acts the part of a follicle to the nail. 
The surface of the corium, on which the nail rests, is termed its matrix 
or bed, and the prominence which surrounds it and overlaps it on its 
two sides and at its root is the Avail of the nail. The surface of the 
matrix is marked by longitudinal ridges, which increase in depth 
from the root towards the extremity, and in the fundus of the fold are 
several rows of transverse ridges ; the ridges are studded with minute 
papillae, which are the active agents in the growth of the nail. The 
papillae of the fundus of the follicle produce the margin of the root, 
and by the successive formation of cells push the nail onwards in its 
growth. The concave surface of the nail is in contact with the derma, 
and the latter is covered with laminse, which perform the double office 
of retaining the nail in its place, and giving it increased thickness, by 
the addition of newly-formed cells to its under surface. It is this 
constant change occurring on the under surface of the nail, co-operat- 

1 Liebig, Organic Chemistry. 



STRUCTURE OF THE NAILS. 69 

ing with the continual reproduction taking place along the margin of 
the root, which insures the growth of the nail in the proper direction. 
For it is clear that if the adhesion of the concave surface of the nail 
with the derma were not perfectly soft and yielding the addition of 
successive layers of cells to the follicular margin would be wanting in 
the force necessary to push it forward in the direction of its growth. 

The nail derives a peculiarity of appearance from the disposition 
and form of the laminae upon the ungual surface of the derma. Thus, 
beneath the root of the nail, and for a short distance onwards towards 
its middle, the derma is covered with ridges, which are more minute, 
and consequently less vascular, than the laminae somewhat further on. 
This patch of ridges is bounded by a semilunar line, of which the 
concavity is turned towards the root, and in consequence of appearing 
lighter in color than the rest of the nail, has been termed the lunula. 
Beyond the lunula the laminae are raised into longitudinal plaits 
(Plate II., figs. 4, 5), which are exceedingly vascular, and give a deeper 
tint of redness to the nail. These plait-like laminae of the derma are 
well calculated by their form to offer an extensive surface, both for 
the adhesion and formation of the nail. The granules and cells are 
developed on every part of their surface, both in the grooves between 
the plaits, and on their sides, and a lamina of nail is formed between 
each pair of plaits. When the under surface of a nail is examined, 
these longitudinal laminae, corresponding with the longitudinal plaits 
of the ungual portion of the derma, are distinctly apparent ; and if the 
nail be forcibly detached, the laminae may be seen in the act of part- 
ing from the grooves of the plaits. This laminated structure upon the 
internal surface of a nail is seen in a magnified form in animals ; for 
instance, in the perpendicular wall of the hoof of the horse. More- 
over, it is this structure that gives rise to the ribbed appearance of 
the nail, both in animals and man. The surface of the derma which 
produces the nail, the matrix of the nail, is continuous around the 
circumference of the attached part of that organ with the derma of 
the surrounding skin, and the horny structure of the nail is conse- 
quently continuous with that of the epidermis. 

That nothing may be wanting to complete the analogy between the 
structure of the nails and that of the epidermis, pigment granules are 
found entering into their composition. The grayness of hue which 
the nails of some persons exhibit is due to the presence of this ele- 
ment, and. upon a microscopic examination of a section of the nail, 
the granules may be observed in greater or less number disseminated 
in streaks amongst the horizontal strata of which the nail is composed. 
Pigment is also found in the deeper cells of the nail of the negro. The 
only difference in structure that has been noted between the epidermis 
and the nail, is the persistence of the nucleus of the cells of the latter. 
While in other respects, the cells of nails undergo a more complete 
condensation and solidification as a consequence of their mode of 
growth, and probably of a more active nutrition. When kept pared, 
nails have a constant and active growth, but when left to themselves 
they attain a certain length and then cease to grow ; as we see in bed- 
ridden persons, and amongst those nations of the East, as amongst the 



70 ANATOMY OF THE SKIN. 

Chinese, who permit the growth of the nail to its full extent. A 
French physician, Dr. Beau, 1 has found that the nails of the feet were 
four times slower in their growth than those of the hands. The latter 
increased in length one millimetre, that is, two-fifths of a line, in one 
week ; while the nails of the foot required four weeks for the same 
amount of increase. According to this observer, the length of the 
thumb-nail, including the root, which is hidden from sight, is eight 
lines, that is, twenty millimetres ; consequently, the period occupied 
in the growth of that nail would be twenty weeks or five months. In 
like manner, the nail of the great toe, measuring in length nine lines 
and a half, or twenty-four millimetres, and requiring four times the 
period of the thumb-nail, would consume ninety-six weeks, that is, 
nearly two years, in its growth. 

Dr. Beau has further remarked, that during the continuance of 
every constitutional disorder the nails suffer to a greater or less ex- 
tent. According to him, the law of growth of the nails is precisely 
the same both in health and disease (an assumption which, although 
not strictly true, approaches sufficiently near the truth to be admitted 
as a general proposition) ; but in the latter state, the materials of 
growth are supplied by the blood in diminished quantity. Hence, 
the portion of nail formed during the existence of disease will be 
perceptibly thinner than that produced during health, and may be 
distinguished on the surface as a transverse groove. If the disease 
have Ijeen sudden, the outer boundary of the groove will be abrupt, 
and vice versd. And if the disease be one in which the nutritive func- 
tions are seriously affected, the depth of the groove will maintain a 
relative correspondence. Admitting these data, Dr. Beau suggests, as 
a practical application of his observations, the possibility of deter- 
mining the period of occurrence and also the period of duration of a 
disease, provided the time do not exceed that required for the entire 
growth of the nail. For example : a groove, or rather ledge, situated 
at the distance of eight millimetres from the edge of the root of the 
thumb-nail, or five from the free margin of the skin, is indicative of 
an attack of disease which commenced eight weeks previously; while 
the breadth of the groove being two millimetres would prove the 
disease to have continued for the space of two weeks. After five 
months the thumb-nail ceases to be a telltale, on account of its entire 
growth in length being accomplished, and the vestige of diseae con- 
sequently obliterated. The great toe-nail, however, may now be 
appealed to. At five months the groove indicative of the above dis- 
ease has advanced only five millimetres from the root, and is only 
just becoming apparent beyond the free margin of the skin, the breadth 
of the groove being only half a millimetre. In making these obser- 
vations, M. Beau selects the thumb-nail and corresponding nail in the 
foot, because in them only he finds the appearances regularly present. 
To put Dr. Beau's observations to the test of experiment, I noted an 
illness which took place in myself, commencing on the 14th of Decem- 
ber, and lasting for a fortnight. On the 1st of May following, I found, 

1 Archives Generales de Medecine, vol. x. p. 447. 



GROWTH OF THE NAILS. 



71 




across each thumb-nail, a groove measuring one line in breadth. Now, 
a line is equal to two and a half millimetres, and as the rate of 
growth, according to Dr. Beau, is one millimetre a week, my illness 
should have lasted two weeks and a half instead 
of two weeks. I therefore came to the conclusion pj g g. 

that, either my own feelings of convalescence 
preceded the perfect restoration of the functions 
of nail-formation, or that the rate of growth of 
the nail was more rapid in me than in other per- 
sons. I next measured the distance between the ' ■ 
distal margin of the groove and the epidermal i 
margin at the root of the nail, and adding to that 
quantity three millimetres for the depth of nail a thumb-nail bearing 
concealed by the follicle, obtained as a result seven- the mark of a foregone U1 - 

.,,. •> • ,1 1 ness - a - Is tne ed g e of 

teen millimetres ; m other words, a space repre- scarf skin which overlaps 
senting seventeen weeks, whereas the real time the nan at its root, b. The 
was nineteen weeks and a half. This was ex- lunula - c - The z Tmve oc " 

■ i-i /> r , i .- -i , casioned by deficient for- 

actly the reverse of my first observation, and went mation during the period of 
to prove that, in me at least, the growth of the nail the illness, a. The free 
was less rapid than is represented by Dr. Beau, extremity of the naii. 
Nevertheless, the experiment came sufficiently 
near the truth to render Dr. Beau's observations interesting and de- 
serving of attention. 

The development of the nail commences during the third month of 
embryonic life, by the prominence of the corium around the boundary 
of the future matrix of the nail ; this prominence is the wall of the 
nail, which marks out a quadrangular area ; and up to the end of the 
third month, the matrix is covered by ordinary epidermis. During 
the fourth month a, harder layer is formed under the epidermis, and 
becomes gradually thicker and larger, until, in the seventh month, it 
protrudes its free edge. The nail is, therefore, developed originally 
under the epidermis, and at a later period only, assumes its external 
position. At birth, in consequence of the growth of the fingers, the 
nail is narrower at the free edge than elsewhere, and is commonly 
broken off, but the whole of the original nail is not worn away until 
the infant is six or seven months old. 

In a chemical analysis of the horny tissue of nail, Scherer 1 found 
the elementary constituents in the following proportions : 

Carbon, . 51.0S9 

Hydrogen, 6.324 

Nitrogen, 1G.901 

?7f n ' \ 25.186 

Sulphur, J 

The chief nitrogenous element is protein with sulphamide ; the 
amount of ash is the same as for epidermis, about one per cent., but 
there was more sulphur and carbon; and, according to Lauth, more 
phosphate of lime, giving additional hardness to the nail. 



1 Liebig, Organic Chemistry. 



72 PHYSIOLOGY OF THE SKIN. 



PHYSIOLOGY OF THE SKIN. 

In a physiological point of view, the skin is an organ of sensation, 
absorption, and secretion; in the former capacity it supplies us with 
knowledge, affords us gratification, and warns us of the presence of 
injurious or destructive agents ; by means of the second, it is enabled 
to appropriate the fluids contained in the surrounding medium, and 
perform the office of a respiratory organ ; and by means of the third, 
it provides for its own softness and pliancy, regulates the influence of 
temperature, both external and internal, and acts as an important 
depurating organ of the blood. 

As an organ of sensation, it endows us with the function of touch, 
of determining the qualities of objects by their properties of resistance, 
of extent, and of variety of surface. It enables us to distinguish be- 
tween hard and soft, smooth or rough, hot or cold. And the educa- 
tion of this sense, effected by concentration of attention, and increased 
powers of appreciation and adaptation, enables the blind to read with 
the aid of their fingers, to trace the most minute variations of form or 
surface, and even to detect the mysterious tactile differences of colors. 

The sensibility of the skin varies normally in different parts of the 
body ; thus, it is greatest on the pulps of the fingers, and least in the 
middle of the limbs, as of the thigh and arm. This has been proved 
by the curious results of the researches of Weber, who applied the 
points of a pair of compasses to the skin, in various parts of the body, 
in order to ascertain the degree of sensibility of the skin in the per- 
ception of a double impression. Thus, upon the pulp of the middle 
finger, the two points were felt when only separated from each other 
to the extent of one-third of a line ; on the palmar surface of the same 
finger it was necessary to separate them two lines ; on the cheek, five 
lines ; forehead, ten lines ; on the middle of the breast, twenty lines ; 
and on the middle of the arm and thigh, thirty lines. He observed, 
moreover, that the delicacy of perception was greatest in the direction 
of the branches of the nerves, as, transversely on the face and front of 
the neck, longitudinally on the fingers, &C. 1 The same author has 
pointed out some remarkable instances of differences in the percep- 
tion of temperature ; thus, he has shown that if the two hands be im- 
mersed in water of the same temperature, that in which the left is placed 
will feel the warmest, while the right is the most sensitive of touch ; 
and again, that a weak impression made upon a large surface of skin, 
produces a more powerful effect upon the nervous system than a strong 
impression upon a small surface. This is practically illustrated by 
taking hot water and immersing the finger of one hand, and the entire 
of the other hand ; the single finger will suffer no inconvenience from 
the heat, while to the hand it may be insupportable. For the same 
reason, the hand is better adapted than the finger to test the tempera- 
ture of a bath before the immersion of the body ; and even then it 
may be found that a heat which is pleasant to the hand may be in- 
tolerable to the entire skin. In pursuing the investigation of the 

1 I have repeated these experiments, and the results are truly surprising. 



ABSORBENT FUNCTIONS OF THE SKIN. 73 

diseases of the skin, we find hourly instances in corroboration of these 
facts. 

The sensibility of the skin is subject to considerable modification 
under the influence of disease ; the natural sensibility may be height- 
ened, or it may be diminished, or, again, it may be altered. These 
changes obviously depend on some modification of the nervous system, 
the nature of which is, for the present at least, beyond our grasp. The 
more common morbid sensations of the skin, in addition to heat and 
cold, are itching, tingling, smarting, pricking, shooting, creeping, 
tickling, burning, scalding, &c. ; and it is to be remarked that these 
sensations are more acute in certain situations than in others, and that 
they are simple modifications of common sensation, and have no con- 
nection with the special tactile function of the skin ; for example, the 
armpits, the sides of the body, and the soles of the feet, are the 
most sensitive to tickling, while the nipple is comparatively insensible 
to the pressure and friction of clothing, but is highly appreciative of 
touch. 

By means of its absorbing power the skin is enabled to act as a 
respiratory organ. The importance of this function in man is not 
sufficiently estimated, but in the lower animals it is universally 
acknowledged. The process of absorption in the skin is effected by 
an active endosmosis, which is more and more controlled by vital 
influence, as it reaches the strata of the epidermis most nearly in con- 
tact with the derma. This function of the skin is calculated to enact 
an important part in the health of the individual, in relation to the 
purity or impurity of the atmosphere in which he moves. 

The absorbing power of the skin, in common with that of the 
mucous lining of the respiratory passages, is actively brought into 
play whenever the body has been exhausted of its fluids, and becomes 
a means of restoring their equilibrium. A gentleman, who was pur- 
suing the practice of the Turkish Bath with great zeal, made at my 
request the following observations on himself, and repeated them 
many times with precisely similar results — and I may observe that 
identical results have attended the same experiment when performed 
by others. On entering the bath he was carefully weighed, and at 
the conclusion of the bath he was weighed again after having passed 
an hour in a dry atmosphere, heated to 180° degrees ; he had lost a 
pound in weight. He then dressed and returned leisurely to his 
home, and after the lapse of two hours was again weighed. He had 
recovered the pound which he had lost in the bath ; he had absorbed 
it from the atmosphere, for he had neither eaten nor drunk during 
the interval. The fact is somewhat startling, and teaches us the 
power of opposition which nature creates to recover an equilibrium 
which we too frequently set ourselves wilfully to disturb. It is a 
powerful argument against the excessive sweating which the pro- 
moters of the dry-air bath have so heedlessly encouraged. The real 4 
Turkish Bath is a bath of low temperature, about 120°, of which the 
atmosphere abounds in moisture, having rills of water streaming over 
its heated floor, and which therefore restores as quickly as it with- 
draws the Avatery fluids from the body — establishing, in fact, a cir- 



74 PHYSIOLOGY OF THE SKIN. 

dilation in the aqueous fluids of the system, and changing its nature 
without altering its quantity. 

When the body is immersed in water of a certain temperature, say 
82° of Fahrenheit, 1 and a few degrees below, and allowed to remain in 
it some time, it increases in weight by absorption of the fluid. The 
fact is proved by the experiments of several physiologists. West- 
rumb 2 detected ferrocyanate of potash in the urine of a man who had 
taken a bath which contained that salt in solution ; and D'Arcet found 
the urine of another alkaline who had bathed in the Vichy waters. 
Other experimentalists have succeeded in discovering coloring matters, 
such as rhubarb, in the urinary secretion after bathing in water con- 
taining such substances ; and Fourcault observed that birds kept under 
water all but their heads, until they died, threw up a watery fluid 
from their stomach. Opposite results to these — namely, loss of weight 
by transpiration — take place whenever the temperature of the bath 
nearly approaches or exceeds that of the body. These experiments 
have another important bearing on the physiology of the skin, since 
they prove that the temperature of a bath which conduces to absorp- 
tion has the effect of a sedative on the system, and diminishes the 
rapidity of the pulse ; while the converse, acting as an excitant of 
exhalation, increases the frequency of the heart's pulsations. 

The absorbent property of the skin is sometimes taken advantage 
of for the purpose of introducing nutritive matters into the system, 
and sit others for the exhibition of medicinal substances. Some of 
the latter produce their characteristic effects when simply applied to 
the surface by means of a bath or poultice ; but more frequently we 
find it necessary to resort to the additional aid of friction, and, more- 
over, we select those parts of the skin in which the epidermis is 
thinnest. The substances to be absorbed must be presented to the 
skin in a state of solution, x>r suspension in water or oil ; but at the 
same time it may be granted that the quantity taken into the system 
is very small. The exhibition of medicinal substances by friction on 
the skin, termed the Iatraleptie method, is only adapted for the more 
powerful medicines, and is rarely employed at the present day, ex- 
cepting in the instances of mercury, croton oil, strychnine, &c. The 
epidermis acts as an impediment to absorption, and as such, is an 
important safeguard against the admission of injurious and poisonous 
substances into the blood. Thus we find that it is only after long 
soaking, or by long-continued friction, that we are enabled to over- 
come this natural defence, and then only to a very partial extent. 
But when the epidermis is removed, the case is altogether altered. 
The derma is a highly absorbent tissue, and medicinal substances and 
poisons, when brought in contact with it, frequently act with as much 
rapidity and energy as when introduced into the stomach. On this 
account, the endermic method, as it is called, offers some advantages 
i when medicines disagree with the alimentary canal, or are repelled 
with loathing by the patient. In the adoption of this method of 
administering medicinal agents, it is necessary to raise a blister in the 

1 Berthokl, in Muller's Archiv. for 1838. 
* Journal Hebdornadaire, No. 7. 



PERSPIRATORY FUNCTION OF THE SKIN. 75 

most expeditious and least painful manner, unless there be an open 
■wound already present, and then sprinkle the substance, in a state of 
fine powder, over the surface. It. follows, "therefore, that only such 
medicines can be administered in this manner as produce their effects 
in very small doses, such as strychnine, morphine, digitalis, bella- 
donna, lead, mercury, &c. The absorbent power of the skin is some- 
times painfully evinced in the inflammation of the kidneys which 
follows the application of a blister, in the constitutional effects result- 
ing from the absorption of lead, or in those which succeed the use of 
arsenic to ulcerated surfaces. 

An observation made by Mr. Ceeley 1 would seem to explain the 
accidental absorption of poisonous substances by the skin, without 
abrasion of the epidermis, and to prove that the confinement of its 
exhalation is an important auxiliary. Thus, he remarks, "I have 
often succeeded in procuring vaccine vesicles without puncture, on 
the skins of children especially, and young persons, by keeping 
lymph in contact with the skin, and excluding it from the air by a 
coating of blood. Active lymph blended with blood casually trick- 
ling down the arm, and drying in the most dependent part, will often 
give rise to a vesicle,." In this case it is obvious that the lymph will 
become gradually dissolved in the perspiratory secretion, an important 
consideration in respect to the prolonged contact of poisonous sub- 
stances with the skin. 

The softness and pliancy of the skin are, in great measure, depend- 
ent on the secretion of the sebaceous substance which is poured out 
on every part of its surface. This secretion is most abundant in situa- 
tions where, from the influence of physical action, the skin would be 
liable to injury were it deprived of a similar covering. Thus we find 
it in large quantities on the head and face, upon the trunk of the 
body, in the armpits, and in the perineum. The sebaceous secretion 
is an oleaginous fluid, containing water, stearine, oil globules, pig- 
ment granules, and salts, together with epidermal cells thrown off by 
the parietes of the glands and ducts. The secretion is modified in its 
qualities in different parts of the body ; in some, by the presence of 
an odorant principle ; in others, by a peculiarity in taste or color. Of 
the former is the butyric acid of the perineal region ; of the latter, 
the yellowish brown and bitter product of the sebiparous glands of 
the meatus auditorius, the cerumen or ear-wax. In chemical compo- 
sition sebaceous substance consists, according to Esenbeck, 2 of 

Fat, ' 24.2 

Osmazome, with traces of oil, ..... 12.6 

Watery extractive (salivary matter), . . . .11.6 

Albumen and casein, ....... 24.2 

Carbonate of lime, ....... 2.1 

Phosphate of lime, 20.0 

Carbonate of magnesia, . . . . . .1.6 

Acetate and muriate of soda and loss, . . .3.7 

100.0 

1 Observations on the Variola Vaccina, in the Transactions of the Provincial Medical 
and Surgical Association, vol. viii. ^ 

a Gerber's General Anatomy, edited by Gulliver. 



76 PHYSIOLOGY OF THE SKIN. 

" The ear-wax is an emulsive compound which contains a soft fat, 
albumen, a peculiar extractive bitter matter, epithelium scales, lactate 
of lime, and an alkaline lactate, but no chlorides, and no phosphates 
soluble in water." 1 

The function of the skin as a regulator of the temperature of the 
body, and as a purifier of the blood, is effected by means of a peculiar 
secretion, the perspiration. When this secretion is eliminated in the 
form of an imperceptible vapor, it is termed insensible, and when 
condensed or poured out in a fluid state, sensible perspiration. The 
insensible perspiration is partly derived from the sudoriparous and 
sebiparous glands, and partly from the natural evaporation taking 
place from the epidermis. The sebiparous system has not been here- 
tofore pointed out as a source of the perspiratory fluid, but frequent 
observation has convinced me that this apparatus plays an important 
part in the elimination from the system of the watery elements of the 
blood. Lavoisier and Seguin estimate the mean quantity of perspira- 
tion, both insensible and sensible, secreted by the skin in the course 
of twenty-four hours, at thirty-three ounces, while they assign to the 
pulmonary exhalation twenty-one ounces — making a total of fifty 
four ounces for both, or somewhat more than* three pounds ; while 
they set down the maximum at eighty ounces, and the minimum at 
twenty-one ounces. The experiments of Dr. Dalton furnished him 
with different results, since he attributes to the lungs an amount of 
exhalation five times greater than that of the skin. 

In some experiments made by Dr. Southwood Smith 2 on the stokers 
of the Phoenix Gas Works, it was ascertained that the maximum loss 
of weight in men who had been at work in a high temperature for a 
period varying between three-quarters of an hour and an hour and a 
quarter, ranged between 2 lbs. 15 oz. and 5 lbs. 2 oz. — -the lesser 
degree of loss occurring on a cold and foggy day — the greater on a 
warm, clear, and somewhat windy day ; and that of two of the men 
placed in a bath of 95°, one recovered half a pound in weight in half 
an hour, and the other lost half a pound in the same space of time. 
The general results of Dr. Southwood Smith's experiments tend to 
show that the amount of perspiration — in other words, of loss of 
weight by perspiration — presents considerable variety in different 
men ; that it presents considerable variety in the same individual at 
different times ; that the subsequent absorption or recovery of the 
lost fluid presents equal variety; and that the amount of loss is 
greater on a warm and clear day than on a cold and foggy day. 

The quantity of perspiration is altered by a variety of circum- 
stances which affect the body physically, or through the agency of the 
nervous system. Of the former kind are the temperature, current, 
and hygrometric condition of the atmosphere, and stimulation of the 
skin ; of the latter, excited or depressed nervous powers. When the 
temperature of • the atmosphere is unusually elevated and the air dry, 
perspiration takes place with so much activity as to preserve the heat 
of the body at its natural standard. If, instead of being still, the 

1 Simon, Animal Chemistnttranslated by Dr. Day. 

2 'Hie Philosophy of Health, &c. 1837. Vol. ii., p. 391. 



SECRETION OF PERSPIRATION. 77 

atmosphere pass over the surface in a current, the quantity of perspira- 
tion is still further increased, and the cooling influence is more felt. 
But if, with the same temperature, the atmosphere be loaded with 
moisture, perspiration is prevented, and the heat of the body becomes 
intense. The influence of stimulation in the promotion of perspira- 
tion is shown in the effects of exercise, the warm bath, diaphoretics, 
&c. Instances of the influence of the nervous system are exhibited 
in the total arrest of perspiration during the hot stage of fever, and of 
its great increase under emotions of a depressing kind, as fear and 
anxiety, and also in syncope. The perspiratory secretion possesses its 
highest amount of activity during digestion, while immediately after 
taking food it is at its minimum. 

The secretion of perspiration is also modified by the greater or less 
activity of the other secretions, particularly of the lungs and kidneys, 
the functions of these organs being frequently vicarious with the 
skin, and vice versa. Thus, during the summer, and in warm climates, 
the perspiratory secretion is augmented, while the exhalation from the 
lungs and the quantity of urine are diminished. In the winter and in 
cold climates the reverse is the case. On quitting a warm apartment, 
especially after indulging in stimulants, for the cold air, a sudden 
check is given to the cutaneous function, while that of the kidneys is 
suddenly and actively called into exercise. The same fact is observed 
in certain diseases; thus, the excessive sweats of phthisis may be re- 
garded as vicarious of the diminished exhalation from the lungs, 
while diabetes is accompanied by a remarkably dry state of the skin. 
The arrest of perspiration again, from cutaneous disease, is often 
attended with serious congestions of the mucous membranes. 

Of some experiments made by Dr. Lining in South Carolina, on the 
relative quantities of perspiration and urine during the warmer and 
colder months of the year, the results are as follows : J 

July, .... 

May, .... 

October, .... 
February, .... 

The influence of the perspiration in regulating the heat of the body 
is strikingly evinced in the numerous recorded instances of exposure 
of the person to elevated temperatures. Sir Charles Blagden sup- 
ported a temperature of 260° for nearly ten minutes. The furnace in 
which Sir Francis Chantrey dried his moulds, and which was frequently 
entered by his workmen, is said to have been kept heated to a tempe- 
rature of 850° ; and the oven used by Chabert, during his exhibitions 
in London, was heated to betwen 400° and 600°. The thermometer 
placed in the mouth of a man who had been exposed to a temperature 
of 120° for a quarter of an hour, stood at 105° ; and the temperature 
of animals when the heat has been raised to a degree sufficient to 
cause death, has never exceeded in elevation from nine to fourteen 
degrees above the natural standard. 2 

1 Dr. Robley Dunglison on Human Health. 

2 It is interesting to note, that in animals made the subjects of these experiments, 



Perspiration. 


Urine. 


. 86.41 


43.77 


. 68.11 


56.15 


. 40.78 


46.67 


. 37.45 


77.86 



78 PHYSIOLOGY OF THE SKIN. 

The effort which is being made to introduce amongst us a bath 
similar to that used in the East, and in some measure resembling the 
ancient bath of the Romans, has afforded new illustrations of the 
effects of heat upon the animal economy, and of the powers with 
which we are endowed of resisting its influence. A temperature of 
150°-180° of dry air to the naked skin is inexpressibly agreeable, if 
the amount of evaporation from the surface be nicely adjusted to the 
degree of temperature — that is, if the quantity of perspiration be 
sufficient, or somewhat more than sufficient, to carry off by evapo- 
ration every particle of heat which might act unpleasantly upon the 
sensations. But if the heat be greater in proportion than the quantity 
of perspired fluid — that is, if there be a less degree of moisture of the 
skin than is equivalent to the carrying off of the excess of heat — 
then a slight feeling of chill, as of a breath of cold air playing over 
the surface, is experienced, and the skin becomes red, dry, and parched. 
Persons who are unacquainted with the cause of this change are apt 
to express their wonder, that while they perspired freely in a lower 
temperature they had ceased to perspire in one that is considerably 
higher ; whereas, in reality, they do perspire more abundantly in the 
higher temperature, but evaporation is rendered more active by the 
increase of heat. 

In a temperature of 250° of dry air, I experienced no inconvenience 
for the first few minutes, whilst evaporation and temperature were 
nicely balanced. Soon, however, I felt faint and uncomfortable, in 
consequence of the excessive demand so suddenly made upon the 
watery fluids of the body ; then, also, a chilly feeling seemed to travel 
over the surface of the skin, accompanied here and there with a dry 
parching sensation ; the skin became dry, red, and congested ; the 
heat had evaporated the moisture of my mouth and fauces, my throat 
felt dry; there was a dazzled sensation in my eyeballs, as though from 
congestion of its vessels; then followed a buzzing sound in the ears, 
apparently from the same cause, and at the end of ten minutes I was 
glad to put an end to the experiment. 

In a damp atmosphere the cooling influence of the perspiration, is 
necessarily lost; and the effects upon the system of a prolonged 
exposure to a moist atmosphere at a -high temperature have been 
recorded by a gentleman who recently visited the baths of Nero, near 
Pozzuoli, the ancient Posidiame. To reach the bath he had to pass 
along a narrow, winding passage of about 120 yards in length, and 7 
feet high, by about three in breadth. A little within the mouth of 
the passage the temperature was 104° in the upper strata of the 
atmosphere, and 91° near the ground ; farther on, the air was filled 

the blood was found in the opposite position to that which it would have occupied 
after death from cold. Instead of being collected about the heart and internal organs, 
as in death ensuing from the latter cause, the heart was empty, and the vital fluid 
dispersed towards the periphery of the body, in some instances being actually forced 
out of its vessels into the surrounding tissues. The blood seemed to have been killed 
by the heat, for it had lost its power of coagulating, and its deep black hue was not 
altered by exposure to the atmosphere — a change which takes place in living blood. 
In a moist atmosphere the animals died sooner than in dry air of a higher temperature 
and without losing weight; in dry air they lost weight. 



SECRETION OF PERSPIRATION. 79 

with dense vapor, of a temperature of 118° above, and 111° below ; 
and over the bath it was 122°, the heat of the spring being 185°. 
After proceeding for about one-third the length of the passage, he 
began to feel a sense of oppression and discomfort, his pulse rising 
from TO to 90 beats in the minute. A short distance farther, the 
oppression increased, his breathing became rapid and panting, and he 
was under the necessity of stooping his head frequently to the earth, 
in order to obtain a chestful of air of a less suffocating temperature. 
His skin, at this time, was bathed in a profuse perspiration, his haad 
throbbing, and his pulse beating 120 in the minute. Continuing his 
progress, the sensations of suffocation became insupportable ; his head 
felt as though it would burst ; his pulse was so rapid as to defy calcu- 
lation ; he was exhausted and nearly unconscious ; and it required 
all his remaining power to enable him to hurry back to the open air. 
On reaching the mouth of the passage he staggered, and nearly 
fainted, and was very uncomfortable until relieved by a bleeding from 
the nose. During the rest of the day his pulse remained at 100 ; he 
had uneasy sensations over the surface of the body, and did not recover 
until after a night's repose. The same gentleman bore a temperature 
of 176° in dry air without inconvenience. 1 

The recent experiments of M. Fourcault 2 throw considerable light 
on the importance to health of the secreting function of the skin. 
These experiments were instituted for the purpose of illustrating a 
theory of the author, that suppression of cutaneous transpiration is a 
potent cause of chronic disease, and especially of scrofula and pulmo- 
nary consumption — diseases which he traces to the conjoint effect of 
a cold and damp atmosphere, and the absence of sufficient exercise to 
promote healthy perspiration. M. Fourcault endeavored to suppress 
the action of the skin in animals by means of an impermeable varnish ; 
and, as a consequence of this operation, he caused vicarious congestion 
of the mucous membranes, and also of the serous membranes and 
nervous system. A horse had intense congestion of the mucous mem- 
brane of the nasal passages and a profuse discharge ; sheep equally 
suffered with congestion of the Schneiderian membrane and coryza ; 
while dogs were seized with inflammation of the bowels, and enlarge- 
ment with congestion of the liver. The respiration became oppressed 
and laborious, and the animal died in a short space of time of asphyxia, 
often accompanied with convulsions. In an animal in whom only 
one side of the body was varnished, the cutaneous capillaries of that 
side were found gorged with dark-colored blood, while on the opposite 
side the blood was of a scarlet hue, and small in quantity. In the 
majority of the animals examined after death the veins near the heart 
were found distended with black soft coagula, and in some there were 
ecchymoses in the lungs. Fourcault found that animals deprived of 
their skin survived longer than those covered with varnish ; and 
reminds us of the poor child, intended to represent the golden age at 
the election of Pope Leo the Tenth, who, being covered with gilding, 
soon after died from the effects of the process. Becquerel and Breschet 

1 Gazette M6dicale, April 27, 1844. 2 Examinateur Mddicale, Oct. 1841, 



80 PHYSIOLOGY OF THE SKIN. 

repeating the experiments of Fourcault in reference to animal tempera- 
ture, conceived that if they could prevent transpiration by the skin, 
they would induce internal fever ; the contrary, however, was the fact. 
After the application of a thick layer of varnish upon the skin of a 
rabbit, and adjusting their thermo-electric needles, they found the 
temperature of the deep muscles, in the course of half an hour, 
reduced from 100° to 8t)° ; in another half-hour to 76° ; and in a third 
half-hour it stood at only 3° above the temperature of the atmosphere, 
63° ; so that, in the course of an hour and a half the temperature of 
the animal had fallen 34°, and the creature died. Fourcault also 
produced albuminuria in dogs by a similar expedient ; the first change 
perceptible in the urine was a diminution of its acid reaction ; then 
albumen became apparent, and at the same time the urine was alka- 
line. He conceives that the detention of the lactic acid salts in the 
blood destroys the equilibrium of organic affinities, and leads to the 
elimination of the albuminous element of the blood. 

The chemical constituents of perspiration are, water, nitrogen, animal 
extract, fat ; carbonic acid with its salts, carbonates of soda and lime ; 
lactic acid with its compound, lactate of ammonia ; acetic acid, acetate 
of soda, butyric acid, chloride of sodium, hydrochlorate of ammonia, 
phosphate of soda and lime, sulphate of soda, salts of potash, and 
peroxide of iron. Anselmino gives the following analysis 1 of the dried 
residue of the perspiratory secretion : 

Matters insoluble in water and alcohol, chiefly calcareous salts. . . 2 

Animal matter soluble in water, insoluble in alcohol, regarded by Ansel- 
mino as salivary matter ('?), and sulphates, . . . . .21 
Matters soluble in dilute alcohol ; chloride of sodium and osmazome, . 48 
Matter soluble in alcohol, osmazome, and lactates, . . . . .29 

100 

Simon collected the perspiratory fluid from the arms and face, and 
found it to be a turbid, dirty-looking fluid, which deposited gray 
floccules on standing. By the microscope these floccules were ascer- 
tained to be epidermal cells. The specific gravity of the fluid was in 
one instance 1003, and in another 1004. It was slightly acid at first, 
but became neutral on standing for twenty-four hours ; and a rod 
moistened with hydrochloric acid, held over it at this period, detected 
the vapor of ammonia. The results of the investigations of Simon 
establish the existence in the normal perspiratory secretion of — 

" Substances soluble in ether : traces of fat, sometimes including 
butyric acid. 

" Substances soluble in alcohol : alcoholic extract, free lactic or 
acetic acid, chloride of sodium, lactates and acetates of potash and 
soda, lactate or hydrochlorate of ammonia. 

" Substances soluble in water : watery extract, phosphate of lime, 
and occasionally an alkaline sulphate. 

" Substances insoluble in water: desquamated epithelium and (after 
the removal of the free lactic acid by alcohol) phosphate of lime, with 
a little peroxide of iron." 2 

1 Muller's Physiology, Translation, page 579. 

2 Animal Chemistry with reference to the Physiology and Pathology of Man. By Dr. J. 



ANALYSIS OF PERSPIRATION. 81 

Dr. Landerer found urea in healthy perspiration in addition to 
phosphates, sulphates, acetates, lactates, chloride of sodium, and 
osmazome. 1 

Dr. P. A. Favre sums up his researches on the chemical composition 
of the perspiration as follows : Its solid components, with the excep- 
tion of a trace, are soluble in water ; its predominant salt is chloride 
of sodium ; alkaline sulphates exist in it in very small quantity; alka- 
line and earthy phosphates are barely discoverable; lactic acid is 
present in the form of lactates ; it possesses a peculiar nitrogenous 
acid, sudoric acid, resembling uric acid in its chemical nature; the 
new acid is combined with alkalies, but uric acid never occurs ;" urea 
is present ; there is but little oily or albuminous matter ; the latter is 
in combination with the alkalies ; the potash is chiefly combined with 
the organic acids, the soda with the mineral acids ; the composition of 
the perspiration obtained under similar circumstances, but at different 
periods, is generally similar ; the organic salts exceed the mineral 
salts at the beginning of perspiration, and vice versa ; the proportion 
of water to the solid constituents remains the same during the entire 
continuance of forced perspiration. 2 

Our information with regard to morbid perspiration is very limited 
and unsatisfactory. Simon made the analysis of this secretion, ob- 
tained from a man who had been the subject of psoriasis vulgaris for 
seventeen years ; but his results are inconclusive, from the fluid being 
in a state of decomposition. Its specific gravity was 1008 ; it smelt 
strongly of hydrosulphate of ammonia, and gave off, when evapo- 
rated, a penetrating odor of sulphuretted hydrogen, which ultimately 
merged into a nauseous animal smell. " It yielded 9.9 of solid con- 
stituents, which, after being exposed to the influence of a red heat, 
were found to consist of a large proportion of chloride of sodium, 
carbonate of soda, a little phosphate of lime, and a fair amount of 
sulphuric acid." The perspiration of "persons with the itch is said 
to have a mouldy odor." And "according to Stark, the quantity of 
free lactic acid is increased" in certain cutaneous affections. 

The gases of the perspiratory secretion — namely, carbonic acid and 
nitrogen — are exhaled in largest quantity after meals or violent ex- 
ertion, the former being most abundant where the food has been 
vegetable, and the latter where the food has been animal. 3 The 
quantity of water excreted by the skin bears reference to the circum- 
stances above detailed — namely, the comparative activity of the ex- 
haling organs, the condition of the atmosphere, and the state of the 
system. The nitrogen, according to Liebig, originates chiefly in the 
decomposition of the atmospheric air carried into the stomach with 
the saliva, or absorbed from the exterior by means of the skin. Dur- 
ing digestion, the oxygen of the atmospheric air enters into combina- 

Fran/. Simon. Translated and edited by Dr. George E. Day, for the Sydenham Society, 
vol. ii. p. 103, 
' Eeller's Archiv., vol. iv. p. 196. 

2 Archives Generates de Medecine, vol. ii. 1853. 

3 Collard de Maitigny, in Magendie"s Journal, vol. x. p. 162. 






82 CLASSIFICATION OF DISEASES OF THE SKIN. 

tion with the food, and the nitrogen is set free to make its way by 
endosmosis through the stomach and diaphragm into the lungs, or 
through the parietes of the body to the skin. It follows, therefore, 
that the quantity of nitrogen set feee in the stomach, and, conse- 
quently, the quantity exhaled by the skin, is proportioned to the 
duration of digestion. Thus, in certain herbivorous animals in whom 
the proeess of digestion occupies a long period, and is increased by 
rumination, a large quantity of atmospheric air is conveyed into the 
stomach, and a larger proportion of nitrogen is extricated from the 
skin, than in carnivora. The same circumstance must take place 
when any cause exists which retards digestion. The quantity of car- 
bon also bears reference to the nature of theingesta: where a large 
quantity of carbonic acid is generated in the stomach, the gas makes 
its way directly to the lungs, as did the nitrogen, or to the skin. Dr. 
Dalton estimates the proportion of carbon eliminated by the skin, irre- 
spective of variety in food, at one-twentieth of the entire quantity of 
perspiratory secretion. To the animal matters, the ammonia, the 
acetic acid, and the lactic acid, are to be ascribed the powerful odor 
of the perspiratory fluid, while its acid reaction is determined by the 
latter. 



CHAPTER II. 

CLASSIFICATION OF DISEASES OF THE SKIN. < 

A good classification of diseases of the skin is one of the first wants 
of the student of dermatology, as it is amongst the first labors which 
have engaged the attention of the professors of this branch of medicine 
from the earliest to the present times. The classification which has 
heretofore served as the framework of the present treatise, and to which, 
fifteen years back, I gave the title of "natural system," was founded 
on the physiology and pathology of the skin, and took as its leading 
characters the phenomena of inflammation of the derma — namely, 
congestion, effusion, suppuration, desquamation, &c. This classifica- 
tion accords in all essential particulars with the arrangement of Willan, 
which is the one pretty universally adopted throughout the world at 
the present day. The claims of the Willanean system to general favor 
are its simplicity and convenience; but like the artificial system of 
classification of Linnams, as applied to the animal and vegetable king- 
doms, to which the same merit is due, it is open to many and serious 
objections; it conveys no idea of the nature and cause of the various 
forms of disease, and, consequently, affords no aid to the comprehen- 
sion of their treatment. 

The artificial system of classification 'of diseases of the skin, or, as 
it may be termed, the Teutonic-English system, from its origin with 



CLASSIFICATION OF DISEASES OF THE SKIN. 83 

Plenck 1 and subsequent amplification and improvement by Willan, 
is attractive to the student and superficial observer, from its easy 
applicability to the discovery of the name of a given disease ; but this 
discovery only too frequently results in the "vox et preterea nihil." 
The tongue that glibly utters the name has no words to tell the cause 
or suggest the treatment ; and the practical physician is naturally 
offended with a system which is all for the eye and nothing for the 
judgment, which embarrasses rather than helps him to the comprehen- 
sion of a correct " methodus medendi." In the consulting-room or by 
the bedside of the patient, he yearns for that fuller knowledge of the 
disease, which will enable him to satisfy both his conscience and his 
self-respect, by guiding him to a correct and successful principle of 
treatment. This object is clearly not to be attained by the artificial 
system ; and therefore, with many others who have similarly felt, I 
have long turned my mind to the construction of a classification of a 
more practical and, I may add, more philosophical kind, embracing 
the conveniences of the artificial system, with the medical fitness of a 
more practical system. 

An etiological system of classification was initiated by Hippocrates, 
when he divided diseases of the skin into local and constitutional ; and 
Hippocrates has been followed in his endeavors by Lorry, Derien, 
Joseph Franck, Plumbe, and more recently by Baumes. 2 

Without venturing to comment on the theories which have served 
as the basis of the classifications proposed by these authors, I will pro- 
ceed to develop the etiological system which has resulted from my own 
researches into the nature of these diseases, and which, I trust, may, as 
an ultimate result, render the treatment of diseases of the skin more 
simple and rational, and remove them from the special and isolated 
position which they at present occupy into the general category of dis- 
eases of the human frame. 'Physicians, no doubt, may still be found, 
who, from taste or superior ability, will pursue, and become eminent 
in, the treatment of these diseases, as a special department ; but there 
will no longer be a reason for the neglect of their study in the general 
education of the physician, nor need their very existence be so com- 
pletely ignored, as is at present the case in our general hospitals and 
medical schools. 

The great family of diseases of the skin admits of division into two 
primary groups ; namely — 

I. Diseases affecting the general structure ; and 
II. Diseases affecting the special structure of the skin. 

The diseases affecting the general structure of the skin, or derma 
proper, are such as implicate at once all the tissues which enter into 
its composition. 

The diseases affecting the special structure of the skin are those 

i Doctrina de morbie cntaneis. Vienna. 177fi. 

* Nouvelle Dermatologie ou precis theorique et pratique sur les maladies de la peau 
fcndti Mir une nouvelle classification m^dicale, &o., par P. Baunies' Chirurgeon en chef de 
l'hospice de l'Antiquaille de Lyon, &c, 1842. 



84 CLASSIFICATION OF DISEASES OF THE SKIN. 

which select its separate components, such as the vessels, nerves, 
papillae, and pigment ; or its special organs — namely, the sudoriparous 
glands, sebiparous glands, hair-follicles and hairs, and nail-follicles and 
nails. 

The diseases affecting the general structure of the skin are divisible 
into five groups as follows : namely — 

I. Diseases affecting the General Structure. 

1. Diseases arising from general causes. 

2. Diseases arising from special external causes. 

3. Diseases arising from special internal causes. 

4. Diseases arising from the syphilitic poison. 

5. Diseases arising from animal poisons of unknown origin, 

and giving rise to eruptive fevers. 

The diseases affecting the special structures of the skin are divisible 
into eight groups, as follows : namely — 

II. Diseases affecting the Special Structure. 

1. Diseases of the vascular structure. 

2. " nervous structure. 

3. " papillary structure. 

4. " pigmentary structure. 

5. " sudoriparous organs. 

6. " sebiparous organs. 

7. " hair-follicles and hair. 

8. " nail-follicles and nails. 

I. DISEASES AFFECTING THE GENEEAL STKUCTURE OF 
THE SKIN. 

Returning now to the first of the primary divisions — namely, 
" Diseases affecting the general structure of the skin" — and taking its 
first group, ''Diseases arising from general causes," I have grouped 
under this head seven typical forms of disease, five of which corres- 
pond with as many orders of the Willanean classification, — namely, 
Exanthemata, Papulae, Vesicul8e, Pustulae, and Bullae. 

The term general, as applied to the causes giving rise to the diseases 
assembled together in this group, is simply intended to convey a 
signification the opposite of special, and to suggest the idea of a cause 
originating in the mal-performance of the ordinary functions of animal 
life, rather than to include a variety of causes. Indeed, in my opinion, 
the whole of the diseases grouped under this head proceed from one 
primary and essential cause, namely, mal-assimilation; in other words, 
from an irritant poison generated in the organism of the individual as 
a consequence of mal-assimilation, the morbid action in the cutaneous 
tissues being a vital process having for its object the elimination of 
that poison by the skin. 1 Arising, then, from one and the same pri- 

1 It is interesting t" glance at the theory of cutaneous disease held by the renowned 
physician Raolanus, wh<> nourished three centuries back: " Sed cur cutis, tot adeoque ; 



CLASSIFICATION OP DISEASES OF THE SKIN. 



85 



mary cause, the variety which is presented in the form and condition 
of the apparent disease, is simply the result of certain phenomena 
which are known to modify and alter the character of disease when 
it attacks other organs of the body — the result, in fact, of predis- 
posing causes, either congenital or acquired. The divisions belonging 
to this group are as follows : 

1. Diseases arising from General Causes. 

a. Erythema, (exanthemata.) c. Eczema, (vesiculas.) 

Pityriasis. Psoriasis. 

Erysipelas. Sudamina. 

Roseola. d. Impetigo, (pustulse.) 

Urticaria. Ecthyma. 

e. Herpes, (bullae.) 

h. Lichen, (papulae.) Pemphigus. 

Rosacea. /. Furunculus, (tubercula.) 

Strophulus. Anthrax. * 

. Prurigo. g. Purpura. 

In the reading of this table Erythema is taken as the type of a 
group of diseases, of which erysipelas, roseola, urticaria, and pityriasis 
are modified forms — pityriasis being, in fact, simply a chronic ery- 
thema. In like manner, rosacea, strophulus, and prurigo are varieties 
of the type Lichen ; and psoriasis and sudamina of the type Eczema. 
I shall explain fully in its proper place my reasons for regarding 
psoriasis as a form of eczema, in fact as a chronic eczema, and taking 
it from a position which it certainly has no right to occupy, namely, by the 
side of Lepra. In an etiological classification, as compared with the 
dermatographic classification or classification of forms, at present in 
use, this change becomes necessary, and will, I believe, be attended 
with no inconvenience. 

2. Diseases arising from Special External Causes. 

The external causes which tend to irritate the skin and give rise to 
disease are few in number, being limited to the presence of parasitic 
animals on, in, or under the skin ; and to the destructive agency of 
heat and cold. Of the class of " diseases affecting the general structure 
of the skin," it is in this group alone that we meet with affections of 
the cutaneous tissue independent of constitutional origin — in other 
words, pure diseases of the skin ; those of the other groups being 
essentially blood-diseases, and depending for their existence on a mor- 
bid condition of the vital fluid. The representatives of the present 
division are — 



Scabies, 
Malis, 



Ambustio, 
Gelatio. 



differentes afTectus patitnr mm sspe ut vix ulla audiatnr tarn frequens qnerimonia ?' 

quia est emissarium commune et sub ea colligitur tertiae cootioni9 superfluitas < i- 

nisi fuliginosa excrementa per cutis spiracula libera expurgentur, .~i stegnosis conni- 

ventia, densitas, astrictio vel obstructio pororum cutis difflatii m impediat quae sub 

cute subsistent excrementa, occasionem dabunt morbis cutaneis." (Johannis Riolani 
Ambiani medici Parisiensis viri clarisimi opera omnia, 1610, p. 548.) 



86 classification of diseases of the skin. 

3. Diseases arising from Special Internal Causes. 

This is an important group, heretofore intermingled with the general 
diseases of the skin, from which, in truth, they are totally distinct. 
In the Willancan classification, they are associated with other diseases 
of the general type in the two orders Squamce and Tubercula; by 
which means their natural affinities are destroyed, and the opportunity 
is lost of considering their relations to each other, and comparing their 
mutual characters. The diseases constituting this group are, — 

Lepra, (squamae, Willan). 

Lupus, (tubercula, Willan). 

Scrofuloderma, " " 

Kelis, " " 

Elephantiasis, " " 

4. Diseases arising from the Syphilitic Poison. 

In the preceding group the cause is unknown or merely hypo- 
thetical ; in this, on the contrary, the cause — namely, the syphilitic 
poison — is well known and universally recognized. The laws and 
phenomena of the syphilitic poison have been made the subject of 
careful investigation, and the facts established by the observation of 
this poison become a guide to the comprehension of the action of 
poisons less known or only suspected, such as in all probability are 
the hidden cause of the diseases assembled in the foregoing group. 
The forms in which syphilis appears in the skin (syphilo-dermata) may 
be classed as follows : 

a. Erythema, c. Tubercula. 

Roseola. Tubercula ulcerantia. 

d. Rupia. 
I. Lichen, e. Alopecia. 

Lichen pustulosus. /. Onychia. 

5. Diseases arising from Animal Poisons of unknown 
Origin, and giving rise to Eruptive Fevers. 

The eruptive fevers originating in special animal poisons — poisons 
of which the phenomena and laws are known, but whose source is 
hidden from our knowledge — naturally form a group by themselves. 
These poisons are three in number, rubeolous, scarlatinous, and vari- 
olous, and the diseases proceeding from them as follows : 

Rubeola, Variola, 

Scarlatina, Varicella, 

Vaccinia. 

II. DISEASES AFFECTING THE SPECIAL STRUCTURE OF 
THE SKIN. 

The speeial structure of the skin being its vessels and nerves, the 
sources of its nutrition and innervation ; its papillae, which determine 
the character of its surface ; the pigmentary principle, which gives 
color to the investing cuticle ; together with its glands, hair, and 



CLASSIFICATION OF DISEASES OF THE SKIN. 87 

nails ; — these become so many heads, under which the morbid affec- 
tions of its particular organs may be considered. Many of the affec- 
tions of these special organs are simply local — in fact, pure diseases 
of the skin, and removed from the influence of the constitutional 
powers, and from the more important category of blood-diseases, which 
compose the first great division of cutaneous affections ; but some 
among them take their source in constitutional disturbance. The 
.number of the latter, however, is not sufficient to render the applica- 
tion of the etiological method of classification to this division a matter 
of advantage. I have therefore adhered, as respects them, to the 
physiological system previously in use. 

In the instance of the vascular structure, the only derangements 
which call for separate consideration are those resulting from simple 
enlargement of the cutaneous vessels, especially the veins ; and, 
abnormal increase of the capillary vessels, giving rise to vascular 
nsevi. In the nervous structure the deviations from the standard of 
health are three in number, as indicated by excess of sensibility, or 
hypersesthesia ; diminished sensibility, or anaesthesia ; and altered 
sensibility, or pruritus. These two groups admit of arrangement as 
follows : 

1. Diseases affecting the Vascular Structure of the Skin. 

Hypertrophia venarum, Naevi vasculosi. 

2. Diseases affecting the Nervous Structure of the Skin. 

Hyperaesthesia, Anaesthesia, Pruritus. 

3. Diseases affecting the Papillary Structure of the Skin. 

The diseases in which the papillae of the skin are chiefly concerned 
are such as result from the enlarged growth or hypertrophy of those 
organs ; they are represented by the wart, the corn, and by callosit}^ 
and thickening of the cuticle ; and may be grouped as follows : 
Verruca, Tylosis, 

Clavus, Pachulosis. 

4. Diseases affecting the Pigmentary Structure. 

Disordered conditions of the pigment of the skin resolve themselves 
into two degrees of development of the pigment as respects quantity, 
and one in which the quality of the pigment is altered. To these I 
have added that change in the color of the skin which is occasioned by 
the internal use of the salts of silver, not from any title it may be 
supposed to possess to consideration in this place, but simply for con- 
venience. It thus forms a fourth head under the name of " Chemical 
Coloration of the skin." 

a. Augmentation of pigment. 
Melanopathia, 
Spilus, 
Nsevi pigmentosi. 



88 CLASSIFICATION OF DISEASES OF THE SKIN. 

b. Diminution of -pigment. 

Alphosis, 
Leucopathia. 

c. Alteration of pigment. 
Ephelis, Chloasma, 
•Lentigo, Melasma. 

d. Chemical coloration. 
Decoloratio argentea. 

5. Diseases affecting the Sudoriparous Organs. 
The disorders of perspiration are, like those of the pigmentary pro- 
duct, reducible to three, namely, excess, defect, and altered quality ; 
as follows : 

a. Augmentation of secretion. 
Idrosis. 
b. Diminution of secretion. 

An idrosis. 
c. Alteration of secretion. 
Osmidrosis, 
Chromidrosis, 
Haemidrosis. 

6. Diseases of the Sebiparous Organs. 
The disorders of the sebiparous organs are somewhat more com- 
plicated and numerous than those of the sudoriparous glands, as may 
be inferred from their greater size and more extensive function. They 
are not alone referable to the three states of excess, defect, and alter- 
ation of secretion ; but also involve the phenomena of impeded ex- 
cretion and inflammation of the gland extending to surrounding 
tissues. They may be grouped as follows : 

a. Augmentation of secretion. 
Stearrhoea simplex. 
b. Diminution of secretion. 
Xeroderma. 

c. Alteration of secretion. 

Stearrhoea flavescens, 
Stearrhoea nigricans, 
Ichthyosis sebacea. 

d. Retention of secretion. 

(Duct open.) (Duct closed.) 

Comedones, Tubercula miliaria, 

Accumulationes sebaceae, Tumores serosi, 

Cornua. Tumores sebacei. 

e. Inflammation of gland and adjacent textures. 
Acne. 

7. Diseases of the Hair and Hair-Follicles. 
The abnormal and morbid conditions of the hairs and hair-follicles 
are numerous, being partly referable to modifications in quantity, di- 
rection, and color of the hair, and partly to disease involving chiefly 



CLASSIFICATION OF DISEASES OF THE SKIN. 



89 



the hairs themselves or the follicles in which they are produced. The 
following arrangement will embrace the whole of these operations : 



a. Augmented formation. 

Hirsuties, 
Nsevi pilosi. 

b. Diminished formation. 

Defluvium capillorum, 

Alopecia, 

Calvities. 

c. Abnormal direction. 

Trichiasis ciliorum, 
Trichiasis coacta. 



d. Alteration of color. 

Trichosis decolor, 
Trichosis cana. 

e. Diseases of Hairs. 

Trichosis furfuracea, 
Trichosis plica. 
/. Diseases of Hair-Follicles. 
Stearrhoea folliculorum, 
Erythema folliculorum, 
Innammatio folliculorum, 
Sycosis, 
Favus. 



8. Diseases of the Nails and Nail-Follicles. 

The disorders of the nails and nail-follicles are referable to altera- 
tions in the growth and texture of the nails, both of which states may 
be included under the term " degeneration ;" and inflammation followed 
by suppuration of the matrix of the nail or onychia; thus, 
Degeneratio unguium, 
Onychia. 

In a tabular form, this classification will stand as follows: 



I. Diseases affecting 

1. Diseases arising 
from General Causes. 



the General Structure of the Skin. 

a. Erythema, (Exanthemata, Willan) 
Erysipelas, 



2. Diseases arising 
from Special External 
Causes. 

3. Diseases arising 
from Special Internal 

Causes. 



Roseola, 
Urticaria. 

b. Lichen, 
Strophulus, 
Prurigo. 

c. Eczema, 
Sudamina. 

d. Impetigo, 
Ecthyma. 

e. Herpes, 
Pemphigus. 

/. Furunculus, 
Anthrax. 
Purpura, 
bies, 

Malis, 

Ambustio, 

Gelatio. 

Lepra, 

Lupus, 

Scrofuloderma, 

Kelis, 

Elephantiasis. 



(Papuhe, Willan) 

(Vesiculae, Willan) 

(Pustuh-e, Willan) 

(Bullae, Willan) 

(Tubercula, Willan) 



9- 

Sea 



(Squamae, Willan) 
(Tubercula, Willan) 



90 



CLASSIFICATION OF DISEASES OF THE SKIN. 



4. Diseases arising 
from the Syphilitic 
Poison. 



5. Diseases arising 
from Animal Poisons 
of unknown origin, and 
giving rise to eruptive 
Fevers. 



a. Erythema, 
Roseola. 

b. Lichen, 

Lichen pustulosus. 

c. Tubercula, 
Tubercula ulcerantia. 

d. Rupia. 

e. Alopecia. 
/. Onychia. 
Rubeola, 
Scarlatina, 
Variola, 
Varicella, 
Vaccinia. 



II. Diseases affecting the Special Structure of the Skin. 
1.* Vascular structure. 



Nervous structure. 

Papillary structure. 
Pigmentary structure. 



Sudoriparous organs. 



6. Sebiparous organs. 



Hypertrophia venarum, 

Naevi vasculosi. 

Hyperesthesia, 

Anaesthesia, 

Pruritus. 

Verruca ; Clavus ; 

Tylosis ; Pachulosis. 

a. Melanopathia, 
Spilus, 

Nsevi pigmentosi. 

b. Alphosis, 
Leucopathia. 

c. Ephelis ; Lentigo ; 
Chloasma ; Melasma. 

d. Decoloratio argentea. 
Idrosis ; Anidrosis ; 
Osmidrosis ; Chromidrosis ; 
Hsemidrosis. 

a. Stearrhoea simplex. 

b. Xeroderma. 

c. Stearrhoea flavescens, 
Stearrhoea nigricans, 
Ichthyosis sebacea. 

d. Comedones, 
Accumulationes sebaceae, 
Cornua, 

Tubercula miliaria, 
Turn ores serosi, 
Tumores sebacei. 

e. Acne. 



GENERAL PATHOLOGY OP THE SKIN. 91 

7. Hair-follicles and Hair. a. Hirsuties ; Nsevi pilosi. 

b. Defluvium capillorum, 
Alopecia ; Calvities. 

c. Trichiasis ciliorum, 
Trichiasis coacta. 

d. Trichosis decolor, 
Trichosis cana. 

e. Trichosis furfuracea, 
Trichosis plica. 

/. Stearrhoea folliculorum, 
Erythema folliculorum, 
Inflammatio folliculorum, 
Sycosis ; Favus. 

8. Nail-follicles and Nails. Degeneratio unguium ; Onychia. 



CHAPTER III. 

GENERAL PATHOLOGY OF THE SKIN. 

Regarding the skin with the view of understanding and arranging 
its pathological phenomena, we find it to present, in the first place, a 
general superficies ; secondly, a glandular apparatus ; thirdly, a cover- 
ing of hairs ; fourthly, an epidermal investment, including the nails, 
and a pigmentary structure ; and fifthly, vessels and nerves. The 
superficies is the most extensive of these parts, and that especially in 
which the first great division of cutaneous diseases, namely, diseases 
affecting the general structure of the skin, is developed ; it will therefore 
be necessary to define' exactly what should be comprehended under 
this term. 

By general sujierficies is to be understood not only the apparent 
surface of the skin, but also that portion of the surface which forms 
the vascular walls of the follicles and excretory ducts of glands. The 
depth to which this latter portion extends is variable, but may be 
supposed to cease before reaching the actual structure of the glands. 
Thus, although appertaining anatomically to the glandular apparatus 
of the skin, the superficial portion of the follicles and of the glands, 
together with their outlets the pores, belongs, in a pathological point 
of view, to the superficies. 

In considering the pathological phenomena of inflammation of the 
superficies, we find erythema, or simple vascular congestion ; lichen, 
or congestion of the pores and superficial portion of the follicles, pro- 
ducing a tumid state of those parts, and constituting pimples ; eczema, 
a vascular congestion, accompanied by effusion of liquor sanguinis, 
lymph, or serum, and giving rise to vesicles; impetigo, a similar 
pathological condition, resulting in the production of pus and pustides ; 
and furunculus, vascular congestion, with loss of vitality of a part 



92 GENERAL PATHOLOGY OF THE SKIN. 

of the structure of the skin. The first four of these pathological states 
are, as we have already seen, the basis of the dermatographic, or 
Teutonic-English classification. They are the exanthemata, papulae, 
vesiculse, and pustulse of Plenck and Willan ; and the congestive, 
depositive, effusive, and suppurative inflammation of my own early 
classification. 

Now, as simple inflammation is capable of, and is the active agent 
in, producing these several morbid conditions of the skin, we are not 
surprised at finding that they are mutually convertible ; that an 
erythema, for example, may become a lichen by the development of 
pimples, an eczema by the evolution of vesicles, or an impetigo by 
the production of pustules. In the same manner, the pimples of 
lichen having subsided, the lymph or ichor of eczema being dried up, 
and the pus of impetigo exfoliated in crusts, there may remain behind 
a chronic erythema, to which another term, psoriasis, has been 
applied. 

Therefore, in essential nature, erythema, lichen, eczema, impetigo, 
and psoriasis, are simply modified manifestations of inflammation of 
the skin, corresponding with recognized stages of common inflamma- 
tion ; the modifications resulting from intensity, cause, and idiosyn- 
crasy, in other words, from accidental conditions. Let me illustrate 
this position by reference to a common and well-known inflammation 
of the skin, scabies, occasioned by a known cause, namely, a local 
irritant, the acarus scabiei. If we imagine an entire family affected 
with this complaint, what shall we find in its various members ? In 
the father, with a sturdy constitution and firm skin, hardened by 
labor, we shall probably find erythema and lichen ; in the mother, 
with a woman's idiosyncrasy, we have erythema, lichen, and eczema; 
in her little girl, a delicate child, erythema, lichen, eczema, and 
impetigo, and so on for the rest. I have verified this observation 
many times over. It is one beyond dispute or doubt, and must 
necessarily lead to the conclusion, that although, in their fully 
developed state, erythema, lichen, eczema, impetigo, and psoriasis, 
are strikingly dissimilar, yet in their pathological nature they may be 
and are essentially the same. 

Let me take another line of argument. A medical man is called 
to a case of inflammation of the skin ; he recognizes an erythema ; 
he visits his patient the next day, it has become an eczema; he at 
once' regards the erythema of the day before in its true light, namely, 
as a stage of inflammation. Instead of an eczema the second day, he 
might have found a lichen or an impetigo. But supposing, as is often 
the case, that the pimples of lichen have subsided, probably been lost 
in the general thickening of the inflamed portion of skin, that all trace 
of vesicles and pustules is gone, but that a chronic state of inflam- 
mation, accompanied by its usual signs, redness, thickening, exfolia- 
tion of cuticle, perhaps chapping, continues — what is the case now ? 
obviously chronic erythema, or psoriasis. Therefore, I repeat, an 
erythema may be, according to the period at which it is viewed, or in 
obedience to accidental circumstances, an erythema, a lichen, an 
eczema, an impetigo, or a psoriasis. 



GENERAL PATHOLOGY OP THE SKIN. 93 

In endeavoring to show the analogy subsisting between the morbid 
affections of the skin and the common source of those I have already 
enumerated, it must not be supposed that I undervalue the distinc- 
tions which at present exist between them. I should be a little 
inclined to dispute the propriety of the terms, helix, antihelix, tragus, 
antitragus, &c, applied to parts of the external ear ; but I can only 
regard them in the same light, namely, as serving to facilitate descrip- 
tion, to enable us to fix with certainty the point of discussion, to assist 
diagnosis and prognosis, and in an equal degree to determine a prin- 
ciple of treatment. But it would be difficult, with the above expla- 
nation before us, to consider them as essentially different diseases, 
and more so as separate orders, or genera, or even species of disease ; 
the utmost rank they can aspire to, is that of varieties of manifestation. 

The light in which I have hitherto placed the typical forms of 
inflammation of the superficies of the skin, is the one most favorable 
to their consideration as separate diseases. I have now to remark, 
that they are seldom found perfectly distinct ; for example, erythema 
is generally present in combination with the others ; and furthermore, 
the united presence of lichen and eczema, of lichen and impetigo, of 
eczema and impetigo, is among the commonest phenomena of cutaneous 
disease. Indeed, so frequent are these unions, that they have been 
thought worthy of celebration by special names ; for example, eczema 
impetiginodes, impetigo eczematoso, &c. ; so that, not only are the 
forms of erythema, lichen, eczema, impetigo, and psoriasis convertible 
into each other, but they are also very frequently found in conjunc- 
tion. How, then, any longer, can we admit them to be separate orders 
or genera of disease ? 

But this is not all the illustration of which the subject admits. In 
the same attack of eruption, the form of disease is different in different 
regions of the body, a difference resulting from the particular organi- 
zation of the part. For example, on the scalp true papulge are never 
seen, and vesicles very rarely. On the hands, and especially the 
fingers, vesicles and pustules are frequent ; but on the rest of the 
surface of the body lichen is the common type. So that, in a general 
eruption occurring upon the entire body, the diagnosis would be 
erythema in one part, lichen in another, eczema in a third, possibly 
impetigo in a fourth, and psoriasis in a fifth. Now, if we conceive a 
disciple of the schools brought in presence of a patient so affected, he 
would gravely inform us that he saw five different and distinct 
complaints belonging to five different orders of disease, and possibly, 
to complete the absurdity, he might think it necessary to prescribe 
five different modes of treatment : whereas, in a practical point of 
view, there is but one disease, an inflammatory eruption, exhibiting 
on various parts of the body the five usual modes of manifestation of 
QUtaneous inflammation, and all amenable to the same treatment. 

The term Erythema (ipuOrj/j.a, rubor) is well chosen to express 
inflammatory redness of the skin without pimples, vesicles, or pus- 
tules. The redness is more or less uniform, and is produced by simple 
congestion of the cutaneous vessels. The inflamed part is but slightly 
swollen, excepting where effusion of serum into the tissues of the skin 



i 



94 GENERAL PATHOLOGY OF THE SKIN. 

has taken place, constituting oedema. It may be acute or chronic. 
The former terminates by subsidence of the redness and exfoliation 
of the cuticle; the latter, from long continuance, produces deeper 
changes — the skin becomes thickened and hard, cracks in the direc- 
tion of the lines of motion, constituting chaps or rhagades, and 
throws off a copious furfuraceous desquamation. It is to the latter 
state of chronic erythema that the term psoriasis is properly ap- 
plied. 

The term Lichen (^/f ; v, summpe cutis asperitas) is applied to that 
form of roughness of the skin, which results from the development of 
pimples (papulae). The pimples of lichen, in their pathological nature, 
are a state of congestion and thickening of the walls of the excretory 
ducts of the skin ; both the congestion and thickening tending to 
raise the pores above the level of the general surface, and constitute 
pimples. In its simplest form, where there is not much congestion of 
vessels, lichen is not to be distinguished from the cutis anserina, pro- 
duced by muscular contraction of the skin, and desertion of the capil- 
laries by its blood. In its more congested form, the papules are 
redder and larger than those of cutis anserina. The papules of lichen 
are never found upon the scalp, the palms of the hands, or soles of 
the feet; in the former situation, probably because the pores are large, 
more firmly retained in" place from their relation to the hairs, and the 
skin between the pores more susceptible of the congestive action. In 
the latter, they do not occur, in consequence of the thickness of the 
cuticle. The papules of lichen vary in size in different regions of the 
body, and at different periods of life ; they are small and hard on the 
trunk and limbs, in the adult; large and soft on the face ; and also 
large and soft in infants, in whom they are termed strophulus. When 
a lichenous papule is examined with a lens, its summit is found to be 
whitish and transparent — an appearance which results from the cone 
of transparent cuticle which occupies the mouth of the dermal follicle. 
This appearance has been mistaken for fluid, and the summits of such 
piiiiples have been described as vesicles containing serum. The true 
vesicle requires no such nice observation ; it is a fair blister, of small 
size it is true, but never so small as to require the aid of a lens for its 
discernment. 

Lichen terminates, like erythema, in subsidence and cuticular exfo- 
liation ; the latter action being kept up for a considerable time when 
the eruption is chronic. 

Such are the characters of simple lichen; but a more severe form 
exists, to which the term lichen agrius [aypux;, fierce) has been given. 
In Lichen simplex, the papules are isolated, and unattended with much 
erythema ; but in lichen agrius, the papules are congregated so as to 
form a cluster of greater or less extent; the heat and itching are 
intense ; the erythema excessive ; and there is, moreover, an oozing 
of an ichorous fluid from the surface, the ichorous secretion being 
abundant when the inflamed surface is rubbed or scratched. In 
almost every smart attack of lichen, patches of lichen agrius occur; 
or they may be found separately, and independent of a general erup- 
tion of lichen. Here, then, we have imported into lichen, essentially 



GENERAL PATHOLOGY OP THE SKIN. 95 

an eruption of dry pimples, a new element, namely, an ichorous exu- 
dation; in other words, the eczematous element; and lichen agrius, 
with a more definite nomenclature, becomes lichen ichorosus, or lichen 
eczematosus. Sometimes the ichorous secretion becomes purulent, and 
small pustules are developed around the inflamed patch ; in which 
case the term lichen impetiginodes might not be inaptly applied. Then, 
after a time, the inflammation subsides, the ichorous exudation is no 
longer produced, but the affected skin remains thickened, is uneven, 
from the presence of numerous cracks and fissures, and coated with 
thin cuticular scales, which are constantly thrown off by exfoliation, 
to give place to a new succession of similar scales. The case is now 
One of psoriasis ; the papules have long since subsided and ceased to 
be apparent, and the pathological aspect is that of a circumscribed 
erythema with thickening of the skin, more or less fissured with 
cracks and chaps, and coated with little flakes or scales of dried cuticle, 
— a chronic erythema, in fact, which in cutaneous pathology is known 
by the name of psoriasis. 

Eczema {h^im ; exferveo, to boil out, or seethe) is the term applied 
to the development of small vesicles on the skin, in combination with 
more or less of erythema. The term does not mean simply to com- 
pare the small vesicles with the bubbles of a seething or boiling fluid, 
but also to take into consideration the heat accompanying that pro- 
cess : "Eas hZiiJ-ara, ab ebullient e fervor e, Grasci vulgo appellant," says 
iEtius. Now, in essential nature, eczema is the same as lichen, 
accompanied like lichen with more or less of erythema, the vascular 
congestion,- as in lichen, being most intense in the walls of the excre- 
tory ducts of the skin, and the vesicles being formed chiefly at their 
outlets or pores. The difference between eczema and lichen is not 
one of cause, but of manifestation — the difference of manifestation 
being chiefly due to difference of temperament and sex. Eczema is 
more common in females than in males, in the sanguine and lymphatic 
than in the choleric and nervous temperaments. Eczema, moreover, 
is never present without lichen, and only becomes eczema when the 
vesicles are in excess over the papules. Eczema may also have a 
mingling of the pustules of impetigo, or the ichorous contents of its 
vesicles may become purulent ; in either case it ceases to be simple 
eczema, and is then eczema impetiginodes. 

The phenomena which I have pointed out as subsisting in lichen, 
and determining the transition of lichen simplex into lichen agrius, 
are also demonstrable in eczema. Eczema may exist as isolated 
vesicles, or vesicles few in number, without inflammation — eczema 
simplex. Eczema may be accompanied by much inflammation — 
eczema rubrum. The ichorous secretion of eczema may become 
purulent, and pustules be developed in the midst of the vesicles — 
eczema impetiginodes ; and eczema may pass into a chronic stage, 
marked by dull redness, a thickened and chapped state of the skin, 
and the production of cuticular scales — into that state, in fact, which 
is denominated psoriasis. 

In the consideration of lichen, I remarked that the summits of the 
papules have a certain transparency, occasioned by an accumulation 



96 GENERAL PATHOLOGY OF THE SKIN. 

of epidermis, a mere anatomical character ; and that this transparency 
has suggested the idea of their containing fluid, and has led to their 
being punctured with a fine instrument, to determine Avhether such 
were the case. Now, the true vesicle is not a doubtful appearance ; 
it requires no rigid examination, no exploration by the needle or the 
lens : it is a little bladder, perfectly appreciable by the eye. It is true 
that it varies in form, being conical when it occurs singly on the 
summit of a papule, as in scabies, and semispheroidal where the 
effusive action is more general. At first it involves the periphery of 
a pore ; by degrees vesicles are formed on the derma between the 
pores, and it is no uncommon thing to see the cuticle raised up to 
some extent, as, for example, completely around a finger, or for the 
space of an inch or more of the surface of the skin. The vesicle is no 
longer unilocular ; it has become multilocular. If the inflammation 
subside, the effused fluid may become absorbed or evaporated, and the 
raised, and consequently dead cuticle, thrown off by desquamation. 
Should the inflammation be kept up, and the quantity of effused fluid 
increase, the softened cuticle will burst, and come away in flakes, 
leaving behind it the inflamed and uncovered derma, moistened by a 
colorless lymph or ichor, which is poured out in considerable quantity. 
In this latter state the separate vesicles are lost, as are the papules in 
lichen agrius, and the diagnosis must rest on the excoriation of surface 
and the abundant effusion of ichorous fluid — in fact, upon characters 
which equally belong to lichen agrius. 

Impetigo, derived, according to Pliny, ah impetu, a bursting forth 
with violence, conveys nothing in its name of the signification which 
we are in the habit of attaching to it, namely, a pustular eruption. It 
is an inflammation of the skin, attacking primarily, like lichen and 
eczema, the mouths of the follicles, and giving rise to an effusion of 
pus. in place of the ichor or lymph of eczema. . The pustules are 
small, sometimes not bigger than the vesicles of eczema ; at other 
times, and especially on the scalp, larger, and sometimes, by conflu- 
ence, spreading over a considerable surface. 

Impetigo is a rarer affection than eczema, and in its pathological 
nature differs from eczema rather in the pyogenic tendency of the 
constitution than in any more essential character. It is, in fact, a 
pustular eczema, just as eczema is an ichorous lichen, and the latter a 
papulous erythema. Impetigo presents, also, another character, which 
lb cniiimon to it with lichen and eczema; it has its "fierce" form, in 
which there is great redness, some tumefaction of the skin, but es- 
pecially the secretion of an abundance of colorless lymph, which is 
often poured forth in such quantities as to saturate all the coverings 
applied to it. In this state, and taking the ichorous secretion as the 
essential character of eczema, this form of the disease, this impetigo 
ichorosus, has been called imjietigo eczematosus, just as the term eczema 
impetiginodes was suggested by the occurrence of eczema in a pyo- 
genic habit of constitution. 

Furunculus (furere, to rage) is a term intended to express a higher 
degree of inflammation of the skin than the " boiling" of eczema, or 
the "impetuous bursting forth" of impetigo, and carries us back to a 



GENERAL THERAPEUTICS OF THE SKIN. 97 

period when mode of development, appearance, or immediate effects, 
formed the basis of nomenclature. In its pathological nature, furun- 
culus, or boil, is an inflammation of a small portion of the skin, slow 
in progress, but intense in operation, and resulting in the gangrene or 
mortification of a portion of the cutaneous tissue. The part of the 
skin especially attacked, and the primary seat of congestion, is the 
vertical portion of the superficies, that, in fact, which constitutes the 
wall cf the excretory duct ; and to this circumstance may probably 
be attributed the mortification of the part primarily inflamed. Con- 
gestion is necessarily accompanied by swelling, and swelling producing 
pressure of the follicle, impedes circulation through its vessels, and 
determines the mortification which follows. The gangrene of furun- 
culus, therefore, is not a consequence of specific inflammation, but 
simply of the anatomical structure of the part inflamed. The morti- 
fied part is the core (coeur) of the boil; it is separated from the living 
tissue like any other mortified part, and is eventually thrown off. 

The size of the boil is determined, firstly, by the nature of the cause; 
and secondly, by the extent of the surface inflamed; it may be a 
single excretory duct; it may be several excretory ducts lying adja- 
cent to each other ; or it may be the excretory apparatus of an exten- 
sive surface, giving rise to an anthrax, or carbuncle. Anthrax (avOpa%> 
a burning coal), or carbuncle, is, therefore, an aggregation of furunculi, 
a furun cuius agrius, and its severity has reference to the consequent 
multiplication of morbid action; it bears to furunculus the same re- 
lation that lichen agrius bears to simple lichen, or eczema impetigi- 
nodes to simple eczema. 






CHAPTER IV. 

GENERAL THERAPEUTICS OF THE SKIN. 



Diseases of the skin present themselves to our notice in the two 
states, acute and chronic; at the three periods of life, infancy, manhood, 
find old age; in different temperaments, normal and abnormal; in 
persons of different idiosyncrasy and diathesis ; and in different con- 
ditions of vigor or debility of the constitution. These diversities in 
the degree of the disease and in the power of the individual constitute 
so many grounds of modification both of the material and strength of 
tlic treatment which should be applied; while other sources of modi- 
fication are met witli in the season of the year, the locality of the 
disease, as upon the scalp, the palms of the hands, the face, &c, and 
Other special conditions appertaining to this class of diseases. 

The treatment of cutaneous diseases divides itself naturally into 
constitutional and local, and in all the degrees of acute or chronic, we 
shall have to consider these two parts of our treatment. These two 
divisions of the subject are the medical and surgical practice of the 

7 



y» GENERAL THERAPEUTICS OF THE SKIN. 

therapeutic art, the physician and surgeon of the medical profession ; 
so that, in the treatment of diseases of the skin, the physician and the 
surgeon must be blended. The two great branches of medical art are 
so nicely balanced in the management of these diseases, that it becomes 
difficult to say which is the more important ; the constitutional treat- 
ment is greatly assisted by local attention; and the local treatment 
would be almost useless without constitutional aid. If I were required 
to discard either, I would retain the constitutional power, and carry 
cutaneous disease into the realm of the physician — in defiance of the 
ancient rule that gives to surgery all that can be reached by the eye 
and by the hand, and to medicine that which is internal and occult. 1 
The etiological principle of classification naturally develops this view 
of the mutual importance of the two branches of the therapeutic 
management of cutaneous diseases; it regards these affections as issu- 
ing from an unhealthy condition of the blood, as being essentially 
blood diseases, and not local or skin diseases. The skin disease is the 
mere symptom, the telltale of the disorder of the blood; and to the 
experienced eye, it not only tells of the existence of disturbance, but 
it likewise tells the cause of the disorder and how that disorder may 
be removed. The local disease in this sense becomes so powerful an 
aid to the interpretation of the general state of the constitution, that 
I believe it quite possible by the mere visual examination of the erup- 
tion, the rest of the patient being concealed by a screen, to declare 
the diathesis of the individual, and to give a general but accurate 
detail of his entire medical history. Cuvier determined the natural 
characteristics, the form, the history of an animal, from a bone; the 
experienced dermatologist may do as much in regard of the constitu- 
tion of his patient, by the inspection of an eruption. 

Cutaneous disease, however acute, rarely calls for depletion by loss 
of blood, either by the lancet or by leeches; however, there can be 
no objection to the removal of blood, if the general fever run high, 
and the severity of the constitutional disturbance seem, in the judg- 
ment of the medical man, to warrant the measure. Diseases of mal- 
assimilation are generally diseases in which the powers of the consti- 
tution are weakly, and moderate purging, with 'effervescent salines, 
which combine with their refrigerant power a diaphoretic and diuretic 
action, are usually all that is needed to subdue the fever of the blood. 

The best remedies of this class are the mildest, namely, the salts of 
magnesia, soda, and potash, either separately or in combination; the 
compound extract of colocynth, with blue pill, ipecacuhan, squills, or 
guaiacum; and as effervescent salines, the liquor ammonias acetatis, 
sesqui carbonate of ammonia, citrate or tartrate of potash, spiritus 
setheris nitrici, and antimony. 

When the acute stage has passed, we must have recourse to tonics, 
bitters with the mineral acids, bitters with alkalies, with or without 
the ferruginous salts, as the haemic or anaemic condition of the patient 
may determine. Every physician has his favorite remedies; as a 

1 Riolanus observes: "Cutanei enim morbi non minus ad medicnm qu&m ad chi- 
rurgura pertinent, imo frequent ins de illis consulitur medicus qu&m chirurgns." 



GENERAL THERAPEUTICS OF THE SKIN. yy 

workman has his favorite tools, and an artist his favorite brushes and 
tints, so I may be permitted to declare in favor of particular remedies : 
of these are gentian, in combination with nitro-muriatic acid ; sulphate 
of quinine with sulphuric acid ; sulphate of quinine with compound 
infusion of roses and sulphuric acid, with or without the addition of 
sulphate of magnesia ; infusion of quassia with sulphate of magnesia 
and sulphuric acid ; gentian or calumba with bicarbonate of potash or 
soda ; citrate of quinine and iron ; citrate of iron in effervescence ; 
tincture of the hydrochlorate of iron with gentian and the mineral 
acids or with phosphoric acid ; tincture of the acetate of iron with the 
mineral acids ; liquor cinchonse with sulphuric acid ; the trisnitrate of 
bismuth with soda or potash, &c. 

In chronic affections of the skin the presence and effects of mal- 
assimilation are more or less obvious ; the complexion of the patient 
is muddy, yellowish, and discolored ; the eye is dull ; the vessels of 
the conjunctiva being sometimes turgid and sometimes anaemic ; the 
tongue is broad, pale, flabby, and indented by the teeth ; the mucous 
membrane of the mouth and fauces is relaxed ; the muscles of the 
whole body are soft ; the heart is weak, easily excited to palpitation ; 
there is more or less dyspepsia, as indicated by acidity of stomach, flatu- 
lence, sinking before taking food, and pain or distension afterwards ; 
often there is weight and uneasiness in the right flank from torpid 
colon ; the bowels are sometimes relaxed, sometimes confined ; the 
urine is sometimes loaded, but mostly pale and abundant ; there is a 
general feeling of languor and lassitude, inaptitude for exertion, men- 
tal or physical, and depression of spirits. And yet, with these symp- 
toms, or at least with some of these symptoms present in a greater or 
less degree, the patient will declare himself perfectly well in heath — 
a declaration which simply amounts to "I eat, drink, and sleep;" he 
forgets to add, But I do all imperfectly, and I have no real enjoyment 
of life ; as a steam-engine I act when the fire is lighted and the steam 
up ; but I am in want of new sockets, new bolts, and an abundance of 
oil to rub off the rust, and ease my movements. 

In these symptoms we see the operation of a mal-assimilation, of a 
cacochymia, which must, before long, lead to the destruction of the 
patient unless presently arrested. In a few words, there is mal-diges- 
tion, mal-conversion, and mal-appropriation of the food taken to 
sustain life ; and the blood recruited from this disturbed and unhealthy 
source becomes loaded with morbid products, in the shape of salts, 
coloring principle, and fluids. If we follow this impure, this contami- 
nated blood through its course, we shall find the organs which it 
supplies injured in their physical state and weakened in their function. 
The muscular system becomes soft and feeble, the heart participates, 
and the foundation is laid for disease of that organ, with all its painful 
train of consequences. The brain and nervous system suffer in an 
equal degree ; the brain, irrigated with mudded blood, can develop 
none but muddy ideas; the intellectuality of the man is deranged, his 
mind depressed, and a state bordering on insanity, in fact, the prompt- 
ings to suicide are at hand. Dyspepsia may be a trifling affection in 
itself, mal-assimilation may be but a small matter when considered 




100 GENERAL THERAPEUTICS OF THE SKIN". 

apart ; but when these conditions, the authors, so to speak, of cutane- 
ous disease, are viewed in relation to their consequences, they may be 
ranked among the most serious of the bodily infirmities of man. 

It may be argued, that the occurrence of these changes in the blood 
has been wisely provided for in the structure of man, by the creation 
of certain organs whose function is to purify the blood, to eliminate 
from the blood its noxious components, to act the part of emuncto- 
ries. This is quite true ; the lungs, the liver, the kidneys, the bowels, 
the skin, are all emunctories, and all sufficient for the purposes of 
health, but insufficient, as is well known, for the necessities of disease. 
Indeed, even for the offices of health, it is an essential condition that 
these organs should themselves be healthy ; but as they, like the 
muscular system and brain, are irrigated with impure blood, they 
also, like those organs, lose their vigor and their power of perform- 
ance of their proper functions, and finally fall into a state of disease. 
Hence, when need is greatest relief is weakest ; the source of help is 
enfeebled, and possibly may fail completely. It does not follow that 
all the emunctory organs should give way at the same moment ; they 
become exhausted by degrees, and yield up their powers in succession. 
For a while the liver performs its office actively, and keeps off the 
pressure from the other emunctories; perchance the kidneys, in addi- 
tion to their own, do part of the work of the rest ; or may be, the 
mucous membrane of the small intestine takes on the duty of a safety- 
valve, and by an inordinate secretion from its surface, constituting a 
permanent diarrhoea, maintains the equilibrium, not of health, certainly, 
but of a state of existence which often passes for such — a spurious 
currency. 

Now, let us consider the state of the human- system thus loaded 
with morbid humors, thus impoverished in its power of eliminating 
them from the blood. A "casus belli," in the shape of a disturbing 
cause, takes place ; it may be mental emotion, muscular exertion more 
than common, a cold wind, a shower of rain, wet feet, some error of 
diet. The organism, in a state of health, has the power of resisting a 
disturbing cause of considerable intensity; but now, in the condition 
before us, enfeebled by the poisonous state of its own blood, it yields 
before one of an apparently trivial kind. The immediate effect of the 
disturbing cause is to depress the nervous energies ; elimination, before 
retarded, becomes suspended, accumulation of morbid humors to 
c.xcos follows, and the organism is for the moment overwhelmed. 
For an instant Nature staggers under the sudden load, but quickly 
afterwards reaction ensues; the "vis vitse" collects all its strength for 
one great effort to expel from the blood its morbid burden ; the morbid 
matter is driven to the surface, causing congestion, and forced elimina- 
tion commences. We may ask what determines the seat of the con- 
gestion? to which the answer is plain, — temperature, season, age, 
idiosyncrasy, previous debility or disease, the predisposing or the 
exciting cause. In the cold seasons of the year, the morbid humors, 
driven for elimination upon the mucous membrane of the lungs, may 
occasion bronchitis; in wanner weather they may be precipitated on 
the mucous membrane of the alimentary canal, causing diarrhoea ; 



GENERAL THERAPEUTICS OF THE SKIN. 101 

under the influence of moral excitement, the result may be apoplexy ; 
or, in other states of the system, gout, rheumatism, or neuralgia ; or, 
in the absence of, or even in association with any of these, the seat of 
elimination may be the skin, and the result an eruption of erythema, 
lichen, or eczema. 

In the treatment of acute disease of the skin, the principle is, as 
we have seen, to subdue the feverish excitement, to neutralize and 
eliminate the morbid salts. In chronic disease, and in the chronic 
stage of acute disease, all this must Be done, and at the same time the 
powers of the system must be kept up; in other words, we must con- 
join with an antiphlogistic, neutralizing, and eliminating plan, an 
invigorating or tonic treatment. Sometimes we meet with instances 
of depression of the animal powers from simple accumulation of 
morbid humors, in which case simple elimination by purgative medi- 
cines strengthens the entire frame, and that which might be presumed 
to lower, actually heightens the power of the patient. At other times, 
and more frequently, we are early made aware that the disease is one 
which, in popular language, is ascribed to "poverty of blood," and 
our tonic system must begin from the commencement of treatment.. 

Let us suppose a patient suffering from chronic cutaneous disease 
sitting before us ; and pen in hand, we proceed to draw up the pre- 
scribed course of treatment ; what are the indications to be fulfilled ? 
They are firstly, to eliminate ; secondly, to restore power ; thirdly, to 
alleviate the local distress. To eliminate, we must secure the proper 
action of the bowels, liver, kidneys, and skin. To restore power, we 
appeal to tonics, which we usually conjoin with eliminants. To allevi- 
ate the local distress, we resort to local means. We will consider these 
indications, with our means to fulfil them, in detail. 

To eliminate, our remedies are purgatives; but in the use of these 
agents, we must endeavor to imitate the operations of nature, who 
works always by gentle means. Our purgatives must be efficient, but 
mild ; the colocynth pill, for example, with blue pill, to secure the 
discharge of the biliary secretion ; henbane, to prevent pain from the 
action of the pill ; and soap, to secure its solution. Sometimes, to 
effect a more decided excretion from the mucous membrane, we may 
add to the compound colocynth pill, ipccacuhan, or squill ; or some- 
times, simply soap. In certain constitutions, a pill composed of the 
watery extract of aloes, with a bitter extract, such as gentian or 
chamomile, acts better than the colocynth pill; sometimes the com- 
pound rhubarb pill, and sometimes a scruple of guaiacum, with ten or 
fifteen grains of the bicarbonate of potash, or a. drachm of tbc bitar- 
trate. The best time for the exhibition of the aloetic and rhubarb 
pill is immediately before dinner, and for the colocynth pill and 
guaiacum, ;if bedtime. They should be continued through the cure, 
unless contra-indicated by an unpleasant effect produced upon the 
patienl ; and they should be taken daily or less frequently, as may 
si'im most desirable. It must, however, always be borne in mind, 
that the safety of the patient demands, before the local excretion is 
checked, that a drain in a more natural direction, and of a more 
natural kind, should be established to supply its place. For this 




102 GENERAL THERAPEUTICS OF THE SKIN. 

reason, I make elimination the first and most prominent of the indica- 
tions to be fulfilled in the treatment of cutaneous diseases. 

To restore power is an indication which must be attempted concur- 
rently with elimination. While the latter carries off the morbid 
humors the former is intended to give tone to the assimilative organs, 
and secure a supply of better and more wholesome nutritive fluid. The 
old material of the organism is to be swept away, while new and 
sounder material is added in its place. Under this head we have to 
consider tonic medicines and a proper system of diet. We exhibit 
tonics on the one hand, while on the other, we keep up an active move- 
ment of the excretions by means of laxatives and purgatives. We may 
select nervo-tonics, such as quinine or quinine and iron ; tonic-elimi- 
nants, such as gentian combined with potash ; or tonic-alterants, such 
as gentian with the nitro-muriatic acid. These remedies may be 
administered twice or three times in the day ; the simple tonics, nervo- 
tonics, and the gentian and nitro-muriatic acid, an hour before meals ; 
the tonic alkalines three hours after meals. If the rheumatic, the gouty, 
or the lithic acid diathesis be present, a preference may be given to 
the tonic alkalines ; but as alkalies, long continued, weaken the crasis 
of the blood, and lower the tone of the system, their effects should be 
watched, and as soon as any lowering action is discovered, they must 
be suspended, and their place supplied by invigorating tonics. The 
nitro-muriatic acid will often eliminate the morbid fluids, without 
being open to the objection of lowering the tone of the system, and 
hence may be substituted advantageously for the alkalies, even from 
the outset of the treatment, and before the lithic acid diathesis has 
been corrected by other means. 

The diet most suitable for cutaneous diseases, and especially those of 
a chronic kind, is a nutritive animal diet, moderate in quantity, but 
sufficient for comfort as well as mere necessity. A judicious blending 
of animal and vegetable food for breakfast ; namely, meat, ham, bacon, 
eggs, butter and bread, with tea, or cocoa made from the nibs, not 
exceeding a single breakfast cup, and abstinence from sugar. Coffee 
is more heating than tea, and a check to the active operations of nutri- 
tion, and therefore not so good ; but if taken, it should be so without 
sugar, or with as little sugar as possible. For the mid-day meal (lunch 
or dinner, as the case maybe), meat, vegetables, and a moderate amount 
of sherry with water, soda-water, or seltzer-water, or any simple 
spirit in place of wine, such as brandy or whiskey. Malt liquor is objec- 
tionable, from the large quantity of sugar which it contains; but other 
vinous drinks which contain no sugar, or a minimum of sugar, may 
be taken, if preferred, such as Bordeaux, Rhenish wines, and dry 
Champagne. Puddings and tarts are prohibited, with the exception 
of plain suet pudding; the whole family of light puddings are indiges- 
tible and detestable. For the third meal of the day (dinner, tea, or 
supper), the second meal may be repeated, the fluid taken with the 
meal being like that of the previous meal, or simply tea without sugar, 
or with the minimum of sugar, as already mentioned. Sometimes the 
third meal of the day is a simple cup of tea, or two small cups, and to 
this, provided sugar be avoided, no objection can be made. When 




GENERAL THERAPEUTICS OF THE SKIN. 103 

this is the case, a fourth meal succeeds (dinner or supper), the compo- 
nents of which have been already considered. There are certain arti- 
cles of diet against which an unfounded objection prevails, and others, 
with as little reason, which are popularly received with favor. Ham, 
salted meats, and vinegar fall into the first category ; water-cress into 
the last. Ham and salted meats, at the present day, are so little injured 
as articles of diet by the process of preserving, that I cannot conceive 
any objection to their occasional use ; certainly more good would result 
from their being taken, if the appetite urged in their favor, than harm 
from their supposed toughness and indigestibility, or from the quan- 
tity of salt which they might be thought to contain. The salted meats 
of the present day are not the salt junk or salted pork of the time of 
Anson's great voyage round the world, when his men were exhausted 
with scurvy, from their exclusive dependence on those articles of food. 
Vinegar is antiseptic, and an aid to digestion : in some constitutions, 
it- produces flushings of the face, and nettle-rash ; but this is an excep- 
tion to the rule, and, as an article of diet, vinegar may be pronounced 
to be perfectly wholesome. I cannot speak so favorably of pickles, 
which come under the designation of crude vegetable matter, which is 
certainly indigestible and difficult of assimilation. Salads are of this 
class, and especially that singularly-favored and supposed antiscorbutic, 
the water-cress. The only redeemable quality of the water-cress is its 
pungency, which gives warmth to the stomach; the mustard and cress, 
on the same principle, give their medicine to the salad, but the salad 
is only rendered less innocuous by the large quantity of aperient oil of 
olives which it should contain.; -> Potatoes may be ranked with objec- 
tionable articles of vegetable diet, and should be taken only in extreme 
moderation. 

We now come to local remedies, which may be divided into two 
classes, — those which simply defend the eruption from external irrita- 
tion, and those which stimulate and produce an alterative action in 
the skin. Of the former kind are water-dressing, fomentations, certain 
lotions, and certain ointments ; of the latter kind are other lotions 
and ointments. The water-dressing, acting as a poultice, facilitates 
the relief of the congested vessels of the skin by promoting secretion, 
and is suitable to the early stages of the disease. But water-dressing, 
too long continued, destroys the tone of the skin, and retards the cure ; 
and the moment must be watched when this remedy has performed 
all the good of which it is capable, to change it for another, which 
will continue the good that has been already commenced. Fomenta- 
tions, either of plain water or decoction of poppy-heads, may be used 
separately or in conjunction with water-dressing ; they relieve heat 
and pain, and facilitate excretion by the skin. The lotions of a cool- 
ing and soothing kind are, — the spirit-lotion, lead lotion, emulsion of 
bitter almonds with hydrocyanic acid, &c. But against all lotions an 
exception may be entered from the first: for a time, ^nd during ap- 
plication, they are agreeable and useful; but when the surface dries 
up, the stiffness, uneasiness, and distress return, and are even greater 
than before. For this reason I rarely make use of lotions as soothing 
or protective remedies. In the next degree to lotions comes a lini- 



104 GENERAL THERAPEUTICS OF THE SKIN. 

ment of oil and lime-water, such as is kept for scalds and burns, which 
may be used either alone or in combination with liquor plumbi or 
tincture of opium. Among ointments of the soothing class are, simple 
cerate with liquor plumbi, simple cerate with camphor, the calamine 
ointment, and the oxide of zinc ointment. 

When first I commenced the treatment of diseases of the skin, 
water-dressing had just been introduced, and suddenly became the 
surgical fashion of the day, while a general outcry was raised against 
ointments — " greasy applications," as they were contemptuously called. 
Finding that in practice it was impossible to contrive any substitute 
for ointments, in the treatment of these diseases, and being unable to 
discover any cause for the objections raised against them by my con- 
temporaries, I set myself to inquire into the possible reasons of their 
disrepute. This was soon ascertained : they were ill-prepared, long 
kept, and, in many instances, so rancid as to act as irritants and ag- 
gravators of the disease. On the other hand, when properly prepared 
and perfectly fresh, ointments are all that can be desired as local appli- 
cations. Again, it is to be remembered that a cutaneous eruption, by 
virtue of the inflammatory congestion which exists, is an actively 
oxidizing surface, and ointments perfectly fresh when applied, are apt, 
by absorption of oxygen, to pass quickly into a state of rancidity. 
Hence we have not only to regard the purity of the ointment in itself, 
but also its tendency, when applied to the inflamed skin, to develop 
those acids of decomposition which constitute the rancid state. Thus 
the same ointment, according to its state of freshness or otherwise, 
may be a soother, or an irritant of the most mischievous kind, when 
applied to the skin. The power of gum benjamin in preventing de- 
composition in ointments is an important discovery, and is now pretty 
generally adopted by our London chemists. This gum, in a state of 
powder, added to the melted lard in the proportion of ten grains to the 
ounce, the ointment being subsequently filtered through paper, not 
only serves to preserve the ointment for a much longer time than it 
would otherwise remain fresh, but also gives it an agreeable odor, a 
condition of some importance where an application is required to be 
kept on the skin during the period required for cure.* 

* Mr. Julius Schweitzer, in a paper published in the "Chemical News" for August, 
1860, on the Unguentum Zinci, details the history of the parent of the oxide of zinc 
ointment, the ceratum de lapide caliminari of Daniel Turner, the Turner*s Cerate of 
the present time. The lapis caliminaris is. as he explains, a native carbonate of zinc ; 
but, being often made of impure materials, and adulterated to please the eye and 
-'■'•in like ilic original, the cerate fell into disrepute, and oxide of zinc was substituted 
in place of calamine, The next difficulty was the procuration of a pure oxide of zinc; 
the old process afforded a very imperfect article, mingled with carbonate of zinc, and 
even with sulphate: l: The Pharmacopoeia of 1836 published a process which produces 
;i pure anhydrous oxide, differing from all the former compounds by its greater 
density, Blighl buff color, and far greater purity." A^ain, the eye test and public 
prejudice did their best to deteriorate this substance ; and, but for the efforts of Mr. 
Redwood, might Lave succeeded. The buff color was thought to indicate impurity, 
which is not the case; but happily an experienced manufacturer, Mr. Hubbuck, 
stepped in and Btipplied an equally pure white oxide; so that we have now two oxides 
of equal purity, and only differing, to all appearance, in .their tint of color. I have 
always given a preference to the ointment made with the buff oxide, without knowing 
why; but Mr. Schweitzer, in his remarks, helps us to an explanation. "Fats and 



■ 



GENERAL THERAPEUTICS OF THE SKIN. 105 

The benzoated oxide of zinc ointment, properly prepared, is the 
most perfect local application for all chronic inflammations of the 
skin that is known. It is cleanly and agreeable, of a cream white 
color, not diffluent and oily like other ointments ; and it has a tendency 
to concrete upon the skin, and constitute an artificial cuticle to an 
irritated and denuded surface. It is rendered further acceptable to 
an inflamed and heated skin by the addition of spirits of wine, in 
the proportion of a drachm to the ounce ; or, if preferred, spirits of 
camphor. The mode of application of this and other ointments is a 
matter for attention ; it should be gently smeared upon the eruption 
with the finger, or, if the diseased skin be too tender, with a camel's 
hair brush, smeared so as to distribute it in a moderately thick layer 
over the whole of the affected part, to introduce it into all the cracks 
and hollows that may be present, and to insinuate it as much as possible 
under any crusts that may have formed on the disease. Once 
properly applied, it will loosen the crusts and prevent further crusts 

oils/' he says, "when in contact or mixed with metallic oxides, soon turn rancid, a 
circumstance which gave dispensing chemists a great deal of trouble with seemingly 
quite simple and unimportant articles of their stock, namely, a few ointments, 
amongst which the unguentum zinci, the most delicate and nicest-looking, may well 
be said to be the principal one. All animal substances will only keep good for a 
limited space of time, and such preparations, as pomatums and ointments may fairly 
be said to be subject to certain deterioration by age; nevertheless it was a well ob- 
served fact, that some of the French pomatums retained their original sweetness for 
an almost unlimited space of time, the cause of which was long a mystery desirable 
to be ascertained. At last it became known that this property was due to an addition 
of gum benzoin, or benzoic acid, a proceeding which in one instance we had already 
adopted. In the preparation of those singular-looking little bottles of pomatum 
known under the name of 'Pomade divine,' amongst a host of other ingredients, we 
are directed to digest gum benzoin with the fat at a gentle heat for about forty-eight 
hours. But it was left to the late Mr. Bell to draw our attention particularly to the 
preservative property of the gum benjamin, of which he proposed to avail himself in 
Be preparation of an unguentum zinci benzoatum. This proposition was eagerly 
accepted, and medical men and chemists will still remember Mr. Bell by this, one of 
his last improvements in pharmaceutical chemistry, — the unguentum zinci benzoatum. 

"This ointment is made by selecting the best and most fragrant gum benzoin, the 
so-called benzoin in tears; this, when comminuted, is added to good fresh lard, in the 
proportion of ten grains to the ounce, and the whole digested in a water bath for 
about forty-eight hours; this, subsequently strained, is used for the preparation of 
the benzoated zinc ointment. 

"In making this ointment with two oxides of zinc, a difference of reaction will be 
observed between the oxide made by combustion and that made according to the 
Pharmacopoeia, which, slight as it may be, deserves nevertheless some attention. 
The buff-colored oxide of the Pharmacopoeia seems readily and speedily to amalgamate 
with tin: benzoated lard, so much so as sometimes to impart to the whole still warm 
fluid a certain consistency, which in far greater degree becomes more observable when 
the ointment is cold. Subsequent experiments showed that the seemingly lighter 
Oxide of combustion resists with greater effect the influence of weaker acids, while the 
dense oxide of the Pharmacopoeia is readily dissolved by them. 

'This chemical difference is in all probability the cause of the different behavior 
of these tu-<> oxides when used fnr the unguentum zinci benzoatum. Benzoic acid is 
readily dissolved by fats and oils; and in digesting the gum for some time with the 
tafd, this acid, as well as the aromatic principles, impregnates the fat, and sub- 
lequently acts on the zinc. How far this greater susceptibility to weak acids may be 
by itself a beneficial application to a wound is a surgical question; but it is a well- 
Know n fact thai many of the most skilful and eminent Burgeons always prefer the 
buff-colored zinc ointment to the perfectly while one made with the new oxide of zinc 
of combustion. ' 



106 GENERAL THERAPEUTICS OF THE SKIN. 

from collecting, while it serves the several purposes of a new cuticle 
to the abraded skin, a water-dressing, and a barrier to the rapidly 
oxidizing action always present in inflammation. If secretions are 
poured out, the eruption may be wiped, but not washed, and a fresh 
application of the ointment may be made morning and night, or as 
often as the previous layer of ointment has been disturbed or displaced. 

If we look upon an ointment when applied in this way to the skin 
in its true light, we shall see that it presents conditions and advan- 
tages which no other local application possesses; and we cannot but 
arrive at the conclusion that it is a most valuable remedy, and one for 
which no equally efficient substitute can be found. It is light, 
produces no pressure, is thin as a film of varnish, and yet excludes 
the air from the inflamed part, thus preventing desiccation and oxid- 
ization, and it retains the ordinary moisture of the skin, acting, as I 
before remarked, as a water-dressing, or natural poultice. Moreover, 
it in no way interferes with the use, at the same time, of other local 
applications which may be thought necessary, such as the evaporating 
lotion, fomentations or poultice. I make it a prominent part of my 
directions, that the morbid part should not be washed after the appli- 
cation of the ointment; it may be wiped with a soft napkin as much 
as may seem necessary ; but when the ointment is once applied, it 
should not be removed by washing without good reason. 

The stimulant and alterative local remedies are lotions containing the 
bichloride of mercury, lotions of bicarbonate of ammonia, acetate of 
ammonia, vinegar, creasote, sulphuret of potash, &c, and ointments of 
the salts of mercury, tar, creasote, sulphur, &c. The intention of 
these applications is expressed in their title; they are intended to 
stimulate in various degrees, to set up a new action, to restore the 
tone of exhausted nerves, and establish an alteration of function ; 
hence the terms stimulant and alterative. The lotion of bichloride of 
mercury in emulsion of bitter almonds, in the proportion of from one 
to three grains to the ounce, is an admirable stimulant in cases of 
torpid skin, such as impacted sebaceous follicles of the face, excess 
of oily secretion, and acne, and is also useful in pruritus. The lotions 
of acetate of ammonia, vinegar, creasote, and sulphuret of potash, are 
also excellent remedies for relieving pruritus. As a stimulant appli- 
cation for chronic erythema and eczematous or lichenous psoriasis, 
there is no better remedy than the unguentum hydrargyri nitratis, 
diluted more or less according to the amount of stimulation required 
to be effected ; it is also admirable in that chronic afl'ection of the 
eyelids, psoriasis palpebrarum. For chronic erythema or pityriasis 
of the scalp, I prefer the unguentum hydrargyri nitrico-oxydi as 
being a more cleanly application ; and for a similar reason, I some- 
times give a preference to the unguentum hydrargyri ammonio- 
chloridi. The questions, to soothe, or not to soothe, to stimulate, or 
not to stimulate, often press themselves on the attention of the medical 
man, and he must be ready to decide these questions when they arise. 
Not unfrequently, the credit of the physician turns upon his decision 
in these simple matters — simple, it is true, only in the abstract ; for 
they may be of vital importance to the patient. I have seen cases 



GENERAL THERAPEUTICS OF THE SKIN. 107 

wherein the mere omission of a too stimulating or an irritating appli- 
cation has been followed by a rapid cure; and the medical man who 
ordered such a remedy has consequently fallen in the estimation of 
his patient. On the other hand, I have seen cases in which a stimulant 
boldly used has brought about an immediate cure. The tact of the 
practitioner lies in the being able to determine which of the two is 
the proper course. In chronic affections of the skin, it often occurs 
to us to see medical men, thwarted by some obstinate disease, have 
recourse to a method which cannot be too strongly condemned, namely, 
that of trying a succession of remedies; and if they be new and 
unknown, perhaps foreign, they seem to have an additional charm. 
The word try implies doubt, uncertainty, experiment ; and the question 
arises, what right have we to make experiments of unknown remedies 
upon our patient? and which of our patients shall we select for the 
purpose ? These are serious questions, and questions that appeal to 
the religio medici. To try a succession of soothing remedies where we 
have determined that the indicator points to soothing, is legitimate ; 
to try graduated stimulants when the soothers have failed, is also 
correct ; and to try a succession of stimulants, equally so. But to try 
like a man in despair, catching at this or that, whichever may come 
first into his mind, without a settled principle of action, is unscientific 
to medicine and dishonest to our patient. It is this which gives rise 
to the frequent instances we meet with, of a succession of changes of 
treatment without plan, without order, and even without the time 
necessary to determine the effects of the varied means ; whereas, 
were the selection of a remedy judicious, and the principle of its 
selection sound, the practitioner would but have to carry it out with 
patience and discretion, to insure an ultimate success. 

Next in order to mercury, I must place sulphur as a cutaneous 
remedy of the class of stimulants ; the simple sulphur ointment of the 
Pharmacopoeia, either alone or with the addition of camphor — the 
unguentum sulphuris hypochloridi compositum — an old remedy, 
revived and much used by myself, and the iodide of sulphur oint- 
ment. The use of sulphur in scabies, as a destroyer of the acarus 
scabiei, is generally recognized, and the simple ointment is perfectly 
adapted to this use. The compound sulphur ointment is an unneces- 
sarily violent remedy for that purpose, and I have never had occasion 
to use it. It must always be borne in mind that sulphur is a stimu- 
lant, and if continued too long, or used too largely, will become an 
irritant also, giving rise to erythema, lichen, and even to an eruption 
of pustules. Hence the apparent perpetuation of scabies in the eyes 
of those who see in that disease only an eruption of papules, vesicles, 
and pustules. But because sulphur is the remedy for scabies, it would 
be absurd to fall into the error of supposing that all eruptions suscep- 
tible of cure by the use of sulphur are therefore scabies. I note this 
error because I have seen it committed, and therefore caution the 
practitioner against it. Where, as in a chronic inflammation of the 
skin of long (hunt inn, such as chronic erythema, pityriasis, or .psori- 
asis, the obvious indication is a stimulant, or discutient, then the sul- 
phur ointment is a good and effective remedy, and in this capacity 



■ 



108 GENERAL THERAPEUTICS OF THE SKIN. 

may be placed by the side of the mercurial ointments. Hence, sulphur 
may be found to cure many varied infirmities of the skin, when the 
stimulating element is the one required. In scabies it is specific; in 
other affections it is simply an individual member of the class of stimu- 
lants. The same remarks apply to sulphur in other forms, and nota- 
bly to the sulphur vapor bath. I have seen sulphur ointment applied 
to the inflamed skin in a case of eczema rubrum. and worse than that, 
in a case of eczema impetiginodes ; a stimulant to an organ in a state 
of acute inflammation, as if the general principles of medicine and 
common sense were to be wholly abandoned, because the case was one 
of skin disease. Suph errors, it is to be hoped, will not be repeated. 
Again, in a case which especially calls for a stimulant application — 
namely, acne — both the indurated and rosaceous kind, the ungu- 
entmn sulphuris hypochloridi compositum is an excellent remedy. 1 

It is not sufficient in medicine to possess a good remedy, it is also 
necessary that we should know how to employ it. To know the 
remedy is a qualification that belongs to the science of medicine ; to 
know how to use it is an attribute of the art of medicine ; and in prac- 
tice the former avails little without the latter. A bad remedy, judi- 
ciously used, is often more advantageous than a good remedy abused 
in its application; and the experience of daily medical life shows that 
much of this want of practical knowledge subsists among us. The 
skilful workman may effect his purpose with bad tools ; but the un- 
skilful one will fail even with the best. Indeed, the success of a 
medical man, his reputation as a healer or theorist, a learned theorist 
maybe, turns upon this talent of application of science to the pur- 
poses of art ; to know it and to do it are not synonymous ; and in 
exerting myself to create a new school of cutaneous medicine, I am 
anxious to make doers in preference to mere knowers. And this, as 
an introduction to the use of the hypochloride of sulphur ointment. 
In the application of a soothing ointment, such as that of the benzo- 
ated oxide of zinc, the contact with the inflamed part shouldbe gentle, 
yet sufficient to reach all the vacuities and interstices of the surface ; 
but in the case of a stimulant, the combination with the remedy of 
another form of stimulation, namely, friction, is not undesirable. This 
remark applies equally to all stimulant topical remedies, which may 
be increased in their stimulant properties to almost any degree by the 
addition of friction. Thus, in a case of chronic indurated acne, I 
recommend the affected skin to be rubbed with a towel before the 
application of the hypochloride of sulphur ointment, and the latter 
to be afterwards rubbed into the skin with a certain amount of fric- 
tion. This is to be done at bedtime, the ointment left in contact 
with the skin during the night, and well washed off with soap and 
water in the morning. The iodide of sulphur, as an ointment, con- 
taining from ten to twenty grains of the salt to the ounce, is a cuta- 
neous stimulant applicable to several chronic affections, and especially 
to sycosis. 

1 The formula for this ointment and other special formulae, referred to in the course of 
the work, will be found in the " selected formuke " at the end of the volume. 



GENERAL THERAPEUTICS OF THE SKIN. 109 

Tar has long enjoyed a reputation in cutaneous diseases, both as 
a specific internal remedy and as a local application. In the former 
capacity we may defer its consideration for the present, and only 
regard it as a local remedy. The forms in which it is chiefly known 
to us are — tar-water, the unguentum picis liquidse et nigrse of the 
London Pharmacopoeia ; the Barbadoes tar, or naphtha; the juniper 
tar, or oil of cade ; and creasote. The tar ointments of the Pharma- 
copoeia are stimulant and antiseptic ; and are mostly used in chronic 
affections of the scalp, and for a class of patients where nicety and 
refinement are matters of secondary moment. The tar-water, Barba- 
does tar, and creasote, are also stimulant and antipruritic ; but the 
most elegant of these remedies is the juniper tar, for which, in the 
shape of ointment, a formula will be found among the " selected 
formulae" at the end of the volume. The juniper tar is also made ap- 
plicable to pruritis of the skin, in the form of an ointment. In that 
most distressing of all the forms of pruritis, namely, pruritus pudendi, 
the juniper tar ointment has proved more successful than any other 
remedy with which I am acquainted. 

Having said thus much on the general remedies applicable to dis- 
eases of the skin, let us now proceed to the consideration of one which 
enjoys a reputation of a specific kind — namely, arsenic. Arsenic is 
known to us as a tonic, as a corrector of mal-assimilation, as a stimu- 
lant of the nervous system, and as a stimulant also of the surface of 
the body, both cutaneous and mucous ; in other words, an alterant- 
cutaneous tonic. Educated on the banks of the Thames, where ague 
is endemic, I have been in the habit of administering arsenic from my 
boyhood, when quinine was a luxury too costly for the agricultural 
laborer and parish pensioner. Arsenic at that time enjoyed a high 
reputation as a tonic and anti-periodic, and properly administered was 
as safe a remedy as bark or quinine; my further experience of arsenic, 
spreading over many years, is equally in its favor ; and administered 
with caution, in proper cases and at the proper time, I believe it to 
surpass every other remedy known. It is a power as simple, as 
manageable, and almost as certain, as the steam-engine, and to my 
thinking is one of the most valuable of the therapeutical possessions 
of medicine, ranking, in this respect, with opium and quinine. 

While vindicating thus warmly the claims to respect of an excel- 
lent medicine, I would equally strongly declaim against its abuse. 
It is known to be useful in cutaneous disease, and therefore it has been 
used in all cutaneous affections ; it is admirable in certain stages of 
some, and the only known remedy in one particular disease ; and yet 
it has been administered indiscriminately in all stages of these diseases, 
and almost without any principle to determine its preference. This 
is a melancholy abuse, disgraceful to our colleges, and disgraceful to 
the profession of medicine, and ought to have a speedy end. 

Arsenic is rarely administered at the present day in its crude form ; 
the Asiatic pill 1 is the only preparation of the arsenious acid that 
occurs to inc. When sulphur first obtained its reputation for the cure 

1 Vide " Selected Prescriptions." 



■ 



110 GENERAL THERAPEUTICS OF THE SKIN. 

of discuses of the skin, it was wont to be taken in its raw state, wherein 
it is found to contain a certain amount of arsenic. But since sulphur 
has been submitted to the refiner, and the arsenic is withdrawn, its 
virtues as a cutaneous medicine have ceased, and it is scarcely used 
now but as a popular remedy. The preparations of arsenic at present 
in use, are, — the arsenite of potash ; arseniate of soda ; arseniate of 
ammonia ; arseniate of quinine ; Fowler's solution, namely, solution 
of the arsenite of potash ; De Valangin's solution, namely, the liquor 
acidi arseniosi hydrochlorici, vel liquor solventis mineralis ; the potas- 
sio-tartrate of arsenic ; iodide of arsenic ; and Donovan's solution, or 
the liquor hydriodatis hydrargyri et arsenici. These different forms 
have each their different conveniences to the prescriber; the combina- 
tions of arsenic with the alkalies and hydrochloric acid are well adapted 
for administration with meals ; the arseniate of soda may be g"en in 
powder or pill ; the arseniate of quinine and iodide of arsenic are also 
suited to administration by pills ; and Donovan's solution is a useful 
combination of iodine and mercury with arsenic. Formulae for these 
preparations will be found at the end of the book. Those which I 
principally employ are, Fowler's solution, De Valangin's solution, the 
arseniate of soda, and Donovan's solution. 

The standard dose of arsenic in skin affections is five minims of 
Fowler's solution, equivalent to 2 ^th of a grain of solid arsenic or 
arsenious acid, tind the frequency of its administration is three times 
a day, making the daily dose amount to |th of a grain, about one 
grain a week, or four grains a month. In this dose, which is as large 
as is ever required for cutaneous disease, the remedy may be taken 
without inconvenience for months, and even for years. In mention- 
ing its medicinal properties I have said that it is a stimulant to the 
mucous membrane, a stimulant to the nervous system, and a general 
tonic ; and to these effects I may add, that it is a local irritant when 
brought in contact with the mucous membrane: exciting in this latter 
capacity, pain, spasmodic griping, and nausea. The art of using 
arsenic with advantage is to escape its inconvenient effects, and en- 
courage such as are favorable to our purposes. To avoid nausea, we 
administer the remedy in its most simple form, and with as little 
offence to the stomach as possible ; thus we distil our five drops into 
the fluid which our patient takes with his meal, or, better still, we drop 
them on a piece of bread, and require that the bread should be eaten 
with the meal; and to render them still less objectionable, I am in the 
habit of prescribing a liquor potassre arsenitis, in which the tincture of 
lavender is omitted; the flavor of the latter being inconsistent with 
our intention of soliciting the favor of the stomach. Again, to insure 
exactitude of dose, I prefer to combine with the arsenical solution some 
simple fluid, such as the tincture of ginger, in the proportion of three 
parts to one, so that the dose becomes magnified to twenty drops, and 
the chances of error of dose diminished in equal proportion. Some- 
times the convenience of the patient is met, by combining the arsenic 
in a pill, in which case the arseniate of soda is the preparation to be 
selected. 

Another precaution in the use of arsenic, and one which is intended 



GENERAL THERAPEUTICS OF THE SKIN. Ill 

to prevent irritation of the mucous membrane of the stomach, and its 
consequences, uneasiness, pain, griping, and nausea, is, its administra- 
tion with a meal, during or instantly after a meal. By this means, we 
secure the admixture of the five drops with the whole mass of the 
meal, its distribution over an extensive surface, its dilution, in fact, 
and we avoid as far as we are able, the contact of the arsenic with the 
mucous membrane. We gain another end, also, by this mode of ad- 
ministration of the medicine : we secure its thorough incorporation 
with the chyme, and its immediate transmission into the blood with the 
chyle and other absorbed fluids. This is a reason why we are enabled 
to eifect a cure with so small a dose ; the whole, or nearly the whole 
of the arsenic, it is to be presumed, is taken into the blood, and is 
thus conveyed into the most favorable position for exerting its medi- 
cinaflpfects. 

While following a course of arsenic, we prohibit our patient crude 
vegetable matter, indigestible articles of food, and excess of acids ; and 
we may be strict or otherwise in this prohibition, according to the 
effects of the medicine. In some persons, the mucous membrane is 
tender and easily irritated ; in others, the arsenic produces no incon- 
venient effect, even- in the midst of dietetic irregularities. Sometimes 
it may be found desirable to administer the remedy twice instead of 
three times a day, and sometimes to reduce the dose to four or three 
minims. In these cases, we may watch the moment for restoring the 
dose to the ordinary standard of five drops. As the standard dose of 
arsenic is extremely moderate, it calls for little variation with differ- 
ence of age ; an infant at the breast will take two minims without 
inconvenience ; from two to seven years, the dose may be three minims ; 
from seven to fourteen, four minims ; and after fourteen, the standard 
dose of five minims. 

I have alluded to one disease in which arsenic is specific and the 
only remedy — I mean lepra ; in this disease we have most experience 
of its use and of its effects. It presents remarkable variety as to the 
time required for producing its constitutional action ; and in this re- 
spect differs essentially from mercury. We can hardly look for any 
indication of its operation on the skin in a less period than from three 
to six weeks, and often this period is protracted to a much longer 
interval. It would seem to be cumulative in its effects, and to reach 
its point of saturation, in other words, to evince its constitutional 
action, suddenly, and often unexpectedly. The completion of satura- 
tion is sometimes announced by congestion of the conjunctiva, and 
sometimes by a rapid disappearance of the eruption from the skin. 
It is a curious phenomenon, to observe with what extraordinary ra- 
pidity a lepra of many years' standing will get quite well, every spot 
vanishing completely, when the happy point of saturation is reached 
by the arsenic. I have repeatedly seen cases wherein no effects were 
visible after months cf regular use of this medicine ; and in three 
weeks afterwards, every trace of the disease had disappeared. 

As arsenic, besides acting on the skin as a cutaneous alterative, is 
also a stimulant of the nervous system and of the mucous membrane, 
and as its action upon these latter must take place during the adminis- 



112 GENERAL THERAPEUTICS OF THE SKIN. 

tration of the remedy, sometimes concurrently with its action on the 
skin, and sometimes independently of that action, we have now to 
consider the nature of these phenomena, that we may stop the use of 
the remedy the instant any symptoms arise which may be deemed 
injurious; in other words, the instant the poisonous effects of arsenic 
begin to be evinced. I have already said, that when acting unfavor- 
ably, arsenic will produce uneasy feelings of weight or sinking at the 
epigastrium, and nausea ; it will also produce vomiting, griping, diar- 
rhoea, sometimes constipation and suppression of urine, dry cough, 
stiffness in the throat, soreness of gums, sometimes. ptyalism, rigidity 
and weight of the eyeballs, and congestion of the conjunctiva ; all 
these symptoms being referable to congestion of the mucous membrane. 
The symptoms referable to the nervous system are, extreme rejdless- 
ness, sleeplessness, sensation of faintness, numbness and tingling^? the 
hands and feet, and headache. Sometimes when the remedy acts with 
more violence on the skin than on other organs of the body, there 
may happen an arsenical erythema. 

Now upon the occurrence of the slighter of these symptoms, as soon 
as they reach the point of real inconvenience or distress, the patient 
is instructed to suspend the remedy, until the feelings of discomfort 
have subsided ; and then to resume it. A suspension of a few days, 
or at most for a week, will, in general, be sufficient for the dispersion 
of the threatening symptoms ; and as soon as this happens, there can 
be no objection to beginning and continuing the medicine as before. 
By taking this simple precaution, I rarely meet with cases wherein 
the arsenic may not be continued for a period necessary for cure, 
unless in persons of peculiar idiosyncrasy, who are unable to take the 
remedy even in the smallest doses. 

And now it may be asked, What are the cases in which the use of 
arsenic is indicated ? Arsenic is applicable to cases of determined 
mal-assimilation when the eruption is chronic from the commence- 
ment, or has passed its acute stage, and the chronic condition is per- 
fectly established ; it is applicable also to those chronic forms of 
eruption which from long continuance are deemed inveterate, such as 
psoriasis ; and it is also applicable, but this time as a specific remedy, 
to lepra. With the exception of lepra, arsenic is not to be employed 
until the general symptoms have been combated by general remedies, 
and until the general disorder of the digestive and circulating systems 
has been removed — not even until ordinary tonics have been given 
without effect, and the tonic alterative powers of arsenic remain as a 
last resource. This is my practice in cutaneous disease, not from any 
fear of the effects of arsenic, but simply because a large majority of 
these cases may be cured by general means judiciously applied and 
steadily pursued; and when all have failed, then comes the time for 
this admirable medicine. The same remarks apply also to lepra when 
complicated with erythema or eczema, as we sometimes find it to 
exist ; in this case, the complications should be first subdued by 
appropriate general treatment, and then the specific employed ; on 
the other hand, when the lepra is simple and uncomplicated, and the 



GENERAL THERAPEUTICS OF THE SKIN. 118 

general condition and tone of the patient moderately healthy, the 
arsenical treatment may be commenced from the outset. 

I have once more to draw attention to the fact of the existence of 
two modes of action of arsenic — namely, its primary or tonic action, 
hy virtue of which it corrects and regulates assimilation ; and its 
secondary or stimulant action, which it exercises on the skin. It is 
in the first of these capacities that it becomes the efficient and curative 
tonic at the close of febrile eruptions, and produces its effects as 
quickly as an ordinary tonic. In its secondary or stimulant capacity, 
it requires time to enter the blood, to diffuse itself through the system, 
to reach and operate upon the tissues of the skin, and probably be 
eliminated by the skin, and to excite in the skin that discutient power 
by means of which the eruption is finally removed. In the latter 
mode of operation it gives rise to congestion of the conjunctiva, con- 
gestion of the skin, commonly denominated arsenical erythema, and 
an erythematous excitement of the patches of lepra which commonly 
precedes their departure. This erythematous condition of the patches 
of lepra, which is the frequent precursor of their dispersion, is one of 
the signs of the constitutional action of the remedy which the deimia- 
tologist looks for with interest ; as is the occasional appearance of a 
fresh outbreak of the eruption after the remedy has been continued 
for a sufficient length of time. 

I have remarked upon the curious fact, that arsenic is well borne 
by infants and young children : in them it evidently exerts its tonic 
influence on the assimilative powers, and evinces its good effects with 
marvellous rapidity. I know of nothing more striking in the practice 
of medicine than the celerity with which one of the most unpromising 
eczemata will get well under the influence of arsenic when judiciously 
administered. I have seen such a case cured in a week, or, at most, in 
two or three weeks, a perfect triumph of medicine. It is clear that in 
these cases the medicine has not time to produce its secondary action 
on the skin, and that the cure must result from its primary tonic 
action on the assimilative organs. 1 

1 I had recently a conversation with a manufacturer of the salts of arsenic, who assured 
me that the men employed in the works experienced no inconvenience from the constant 
inhalation of that substance, nor was their longevity influenced by the nature of their 
occupation. Mr. Arthur Church, in a note published in the "Chemical News" for 
August, 1860, on the arsenical water of Whitbeck in Cumberland, after stating that the 
water contains a very perceptible amount of arsenic, namely, a fraction of a grain to 
each gallon, "probably derived from the veins of arsenical cobalt ore through which 
it percolates," observes : "The arsenical water is habitually used for every purpose by 
the inhabitants of the little village of Whitbeck, and, as far as I can learn, with benefi- 
cial rather than injurious results. But it is remarkable that Whitbeck, though in every 
respect suitable for trout, is the only stream in the neighborhood from which that fish 
U absent; eels, however, have been found in it. Ducks will not live if confined to this 
arsenical water. When the railway was being carried past Whitbeck, the first use of 
the water quickly produced the usual marked effect on the throats both of the men and 
horses employed on the works. The soreness of mouth from which they at first suffered 
soon however disappeared, and in tin' horses gave place lo that sleekness of coat assigned 
as one of the effects produced by the administration of arsenic. It is a question how 
far the rosy looks of the Whitbeck children, and the old age which a large proportion of 
the inhabitants of the village attain, are to be attributed to the arsenic present in the water 
they drink." 

8- 



114 GENERAL THERAPEUTICS OF THE SKIN. 

Tar and pitch, used as internal remedies, probably act upon the 
skin as eliminant stimulants, and require to be taken for a long 
period to produce their effects. They may be employed where there 
is great intolerance of arsenic, and in similar cases, but I do not attach 
any value to them as a medicine. Pitch is administered in the form 
of pills, of which a large number have to be taken daily ; but a more 
efficient remedy is the Barbadoes tar, which is inclosed in capsules, 
and requires the exhibition of a less quantity. The cases to which 
tar is particularly suited, are chronic erythemata, including pityriasis 
and psoriasis, and lepra. I have not had much experience of their 
effects, believing that I had other, more active, more convenient, and, 
I may add, more certain remedies within reach ; and it has only been 
as a variation to the arsenical course, or in persons who were mable 
to take arsenic for a sufficient time to be useful, that I haWhad 
recourse to them. 

Cod-liver oil has been spoken of in connection with cutaneous 
diseases, and cod-liver oil has consequently been made the subject of 
trial; sometimes with benefit, and sometimes the reverse; the usual 
fate of good remedies tried without any principle to guide or deter- 
mine their use. I have said that I regard mal-assimilation as the 
essence of cutaneous disease; with mal-assimilation there is necessarily 
more or less of mal-nutrition, and Avith the latter emaciation. Now, 
these are the cases for cod-liver oil, and in them cod-liver oil is an 
excellent remedy. Cod-liver oil improves nutrition ; with improved 
nutrition there is an advance of general power ; and with general 
power, a better assimilation returns. The medicinal virtues of cod- 
liver oil are therefore such as result from its easy adaptation to nutri- 
tion ; in this sense it becomes an admirable tonic, like beef and mut- 
ton, but one which may be employed when the appetite is opposed to 
the latter. Some time back, it occm-red to me to make trial of cod- 
liver oil in a dietetic form, and with the willing aid of an ingenious 
chocolate manufacturer [Mr. Lebaigue, of No. 9 Langham Street, St. 
Marylebone, by whom this chocolate is now manufactured under a 
patent-right, to secure its purity ; its price is four shillings the pound, 
each pound containing four ounces of cod-liver oil, or one part in 
four ; the pound is grooved into thirty-two tablets, each of which, 
therefore, contains one drachm of oil and three of chocolate, and may 
lie taken as a dose] I soon had at my disposal an ample supply of cod- 
liver oil chocolate, and believed that with a dietetic substance of this 
kind, I should be able to overcome the repugnance which some per- 
sons, children in particular, have to swallowing oil ; that I should pre- 
sent the oil to the stomach in a state more favorable for the assimi- 
lating process; that I should escape the nausea resulting from the 
presence of undigested oil in the stomach, and that a small quantity 
of oil would be more effective than a larger dose administered in its 
crude state. My anticipations in all these particulars were fully borne 
out by the result, and I found myself in possession of a valuable 
dietetic medicine. To be quite certain of its powers, I confided it to 
my brother to use among my poorer patients ; and he reports to me 
that he found it most serviceable with children; that in many instances 



GENERAL THERAPEUTICS OF THE SKIN. 115 

he used no medicine but a simple aperient to regulate the bowels, 
and that the improvement in the condition and disease of these 
children, in the course of a week, was really marvellous. He observes, 
moreover, that the cases which he selects for the use of the chocolate 
are such as evince a distinctly mal-assimilative or cachectic diathesis, 
a lymphatic or pyogenic tendency, and more or less of emaciation; 
these being the subjects in which eczema impetiginodes and impetigo 
eczematosum mostly prevail. 

As cod-liver oil has been tried internally, so cod-liver oil has been 
tried externally, by way of inunction through the skin; and cod-liver 
oil has been reported to be an excellent remedy, externally applied 
in cutaneous disease. There can be no doubt that, used by way of 
inunction, some portion of the oil is absorbed into the blood, and 
applied to the purpose of nutrition, becoming, in fact, an internal 
remedy. But as far as its real external powers are concerned, cod- 
liver oil possesses no virtues greater than any other oil, or even lard, 
which brings us back to the use of ointments ; the true value of which 
we shall perceive at once, if we compare the dry, parched, exfoliating, 
cracked, oozing skin of cutaneous disease, with the moist, pliant, soft, 
integument saturated with oil or lard. 

Besides the more apparent properties of oily matters applied to the 
skin, their deoxidizing powers are to be borne in mind ; and as oxygen 
is the great' stimulant of chemical action generally, and of the chemical 
processes taking place in the blood of an inflamed part, the value of 
this power of fencing off the oxygen cannot be estimated too highly. 
This power I claim for ointments, as applications to eruptions of the 
skin. The plan of inunction by the skin in measles, scarlet fever, 
and small-pox, has been successfully pursued in Germany, and I have 
adopted it in my own practice with great advantage. It not only 
diminishes the heat and pruritus of the surface, but, by checking the 
formation of the poison in the capillaries of the skin, reduces materi- 
ally the general fever. Upon the same principle, carbonic acid gas 
becomes a valuable remedy in states of inflammatory congestion of 
the skin, in irritable eruptions and ulcers, and is probably the bene- 
ficial agent in that excellent topical application, the yeast poultice. 
In selecting an oleaginous substance for inunction by the skin, I 
should prefer fresh lard or fresh neat's-foot oil to the cod-liver oil. 

Glycerine, during the last few years, has been largely used as an 
application for the skin, and was first introduced to the notice of the 
profession by Mr. Startin. Struck by the peculiar and paradoxical 
properties of this singular fluid, which up to that time had been 
regarded as a useless product, and was allowed to flow away into the 
sewers of the Thames, this curious substance, sweet as syrup, without 
containing a particle of sugar or fermentable matter, and mixing with 
#ater with the utmost case, although extracted directly from oil, was 
preserved by Mr. Warrington of the Apothecaries' Hall, under the 
hope that some day a use might be found for it, whenever it came to 
be more generally known. Mr. Warrington's expectation was soon 
realized ; lie mentioned it to Mr. Startin, and afterwards to me, and 
it became suddenly called for by the profession, to a greater extent 



116 DISEASES ARISING FROM GENERAL CAUSES. 

than could be supplied. It was necessary, therefore, to manufacture 
glycerine; and that substance which a few months before had been 
wasted as an effete and useless product, was now manufactured at the 
sacrifice of the materials out of which it was formed. As it originally 
existed in the carboys preserved by Mr. Warrington, glycerine was 
perfectly free from odor ; it had been produced by the decomposition 
of the oil which takes place in the manufacture of lead plaster. Now, 
having becoine a valuable and costly medicine, new sources of supply 
were opened, and among others, that of the soapboiler ; and the gly- 
cerine derived from this source was so offensive in smell, that for a 
time I discarded its use, and glycerine fell into the danger of being 
dismissed altogether from our Pharmacopoeia ; subsequently, Mr. 
George Wilson, one of the managing directors of Price's Patent Candle 
Company, discovered a method of separating glycerine by distillation 
from the materials used in their manufactures, and has succeeded in 
producing it perfectly free from smell, of a purer quality than that 
heretofore in use, and in a quantity which renders its exhaustion at 
any future period very improbable. 

Glycerine is an exceedingly useful therapeutical preparation in all 
cases where dryness, scaliness, or scurfiness of the cuticle is the pre- 
dominating feature; for example, in that general dryness of the surface 
which I have called xeroderma, in pityriasis, and notably in the 
extreme dryness of the palms of the hands which accompanies psori- 
asis palmaris. It may be employed either in its pure state, or more 
or less diluted in the form of a lotion. I have not found it a good 
remedy in irritable erythemata nor in eczema, and I confine its use 
exclusivelv to the cases mentioned. 



CHAPTER V. 

DISEASES ARISING FROM GENERAL CAUSES. 
ERYTHEMATOUS OR EXANTHEMATOUS ERUPTIONS. 

The eruptions belonging to this group, of which erythema, inflam- 
matory blush, is taken as the type, are four in number; namely, 

Erythema, Roseola, 

Erysipelas, Urticaria. 

These eruptions correspond with the exanthemata of Willan ; but 
Willan included besides, under the same head, scarlatina, rubeola, and 
purpura, while he omitted erysipelas, considering that in his order 
Bullae. I have thought it more consistent with the present state of 
knowledge to treat of scarlatina and rubeola among the eruptive 
fevers, as being diseases originating in an animal poison of unknown 
origin. Purpura I have placed apart, as belonging to a group re- 



ERYTHEMATOUS OR EX A NTH E M AT U S ERUPTIONS. 117 

markable for dyscrasis of the blood and tissues, while the bullae of 
erysipelas may be considered as almost an accidental character, being 
frequently altogether absent. 

I have committed violence to Willan's system, in respect of another 
affection, which I have taken from his order Squamae, and placed in 
this group, as a variety, or rather as a form of chronic erythema, 
namely pityriasis. Pityriasis is evidently an erythema, attended with 
exfoliation of the epidermis, the exfoliation being furfuraceous, and 
probably more copious than in the simply congestive forms of this 
affection. But the latter character cannot be considered sufficient to 
transfer it to a different order, and to associate with it a specific affec- 
tion so entirely distinct as lepra. All the natural affinities of Pity- 
riasis sufficiently point it out as an erythema. 



ERYTHEMA. 

Syn. Inflammatory blush. Efflorescence cutanee, Fran. — Hautrothe, 
Germ. — Dartre e?°ythemo'ide, Alibert. 

Erythema 1 (Plate I., G. — K.) is a superficial inflammation of the skin, 
characterized by a diffused or circumscribed redness occurring in one 
or several patches of irregular form, and varying from a few lines to 
several inches in extent. It is non-contagious, occasionally produced 
by local irritation, but generally symptomatic of constitutional or 
visceral disturbance. In the commencement of erythema the derma is 
a little swollen ; the swelling, however, speedily subsides, the redness 
remaining for a much longer time. Upon the dispersion of the red- ' 
ness, the skin retains for some days a purplish and bluish tint, and the 
epidermis exfoliates in the form of a furfuraceous and laminated 
desquamation. 

There are two degrees of erythema — acute and chronic ; acute 
erythema presenting eight principal varieties — namely, 

Erythema fugax, Erythema intertrigo, 
" circinatum, " papulatum, 

" marginatum, " tuberculatum, 

" lseve, " nodosum. 

These varieties admit of arrangement into three groups — sympto- 
matic, local, and general or idiopathic. The symptomatic kinds are 
erythema fugax, erythema circinatum, and erythema marginatum. 
The local group comprehends erythema laeve, a disease depending on 
the local condition of the limb, and very appropriately designated by 
Good, erythema oedematosum ; and erythema intertrigo, the conse- 
quence of local irritation. The general or idiopathic varieties are ery- 
thema papulatum, tuberculatum, and nodosum, which are preceded 
and accompanied by general febrile symptoms, and are closely allied 
with each other. 

1 Der. tpvbaimv, to redden. 



118 DISEASES ARISING FROM GENERAL CAUSE; 



ERYTHEMA FUGAX. 

Erythema fugax appears in the form of diffused patches of redness, 
which are variable in depth of color and extent, and occur for the 
most part on the upper regions of the body, as upon the face and 
neck, the trunk, and the arms. The redness of this form of erythema 
is especially characterized by its evanescent and fleeting disposition, 
one while vanishing suddenly, to reappear at successive periods ; 
another while subsiding on one spot, to break forth on several ; and 
again continuing fixed for a short period, to disperse slowly and by 
degrees. It is attended with considerable heat and dryness of surface, 
and sometimes by swelling. At its decline, the epidermis is left rough 
and furfuraceous, from the disturbance to which the formative func- 
tion of the derma had been subjected. 

Erythema fugax is chiefly important as a symptom of visceral 
derangement, and in some instances it may be regarded as an indica- 
tion of the long continuance and danger of such disorder. It is 
particularly noticed in connection with irritation of the mucous tis- 
sues of the body, as of the alimentary mucous membrane, the respi- 
ratory membrane, the generative membrane, and the urinary mucous 
membrane. In my notes for the past three years, I find references to 
cases in which this form of exanthema has appeared in conjunction 
with dyspepsia, diarrhoea, hepatitis, bronchitis, hysteria, anomalous 
uterine irritation, pregnancy, inflammation of the kidneys, &c. It is 
also seen in some nervous affections and fevers ; and Willan records a 
fatal case of puerperal fever in which erythema fugax was a con- 
spicuous symptom. This inflammation is most frequently observed in 
the female sex. 

I had lately under my care a striking instance of this affection in 
the person of a young military officer, who was not aware of any 
disturbance of his general health. The efflorescence was attended 
with swelling, Avould come on in the course of an hour, and after the 
continuance of a few hours subside as rapidly as it had appeared. 
His attention was generally drawn to the seat of the disease by some 
degree of itching, and on examining the part, the redness and swelling 
were perceived. Trifling as the disorder appeared, it was a source of 
serious annoyance ; it sometimes made its appearance while he was 
engaged on military duty, or dressing for a dinner party, fixing, for 
example, upon the cheek, and closing his eye by tumefaction of the 
lids. . 

ERYTHEMA CIRCINATUM. 

Erythema circinatum (Plate I., K.) appears in the form of small, 
round, and very slightly raised patches of redness, which enlarge by 
their circumference, while the redness in the centre fades and disap- 
pears. In this manner, a number of rings with broad margins are 
produced, which run over the surface of the affected region, and, as 
they increase, communicate by their borders, and give rise to a num- 
ber of irregular and broken bands resembling segments of circles of 
various magnitude. The central portion of the rings, and the surface 



ERYTHEMATOUS OR EX ANTH EM AT U S ERUPTIONS. 119 

which has been left by the erythema, has a yellowish tint, and throws 
off" a fui'furaceous desquamation. The duration of erythema circina- 
tum is greatly dependent on the nature of the disease with which it is 
associated ; it may be stated generally at from a few days to two or 
three weeks. 

I have before me the notes of a case of this form of erythema, 
associated with acute rheumatism, which occurred in the hospital prac- 
tice of Dr. Watson. The spots were first developed on the abdomen, 
and quickly spread from this point as from a centre, until they had 
occupied with their curves the whole surface of the trunk of the body 
and limbs. The case in other respects presented no characters different 
from ordinary rheumatism ; the symptoms of the latter were neither 
aggravated nor relieved by its invasion, and it appeared to be de- 
veloped in connection with augmented perspiration. 

ERYTHEMA MARGINATUM. 

Erythema marginatum is an aggravated form of erythema circina- 
tum, occurring, for the most part, in association with chronic visceral 
disorder, and in elderly persons. In this variety there is a greater 
degree of congestion of the skin than in the preceding ; there is a 
deeper but variable tint of redness, which frequently approaches to a 
purplish hue ; the border of the circles is more raised, and slightly 
papular, and the margin is abrupt and well defined. Like erythema 
circinatum, the present variety presents considerable difference of 
appearance at different stages of its progress; at one time exhibiting 
a distinctly annular form, at another, an assemblage of raised and 
inflamed bands, having more or less of a curved direction. This 
diversity of appearance of the disease at different stages of its progress 
enables us to comprehend the apparent dissimilarity in the definition 
of erythema marginatum, as given by Willan and Bateman, and by 
Rayer. The latter of these authors describes the early stage of the 
exanthem, when he remarks that it consists of "circular patches of a 
livid red, from half an inch to an inch in diameter, the circumference 
of which is distinctly separated from the healthy skin, raised, promi- 
nent, and slightly papular ;" while Willan and Bateman, taking the 
latter stages as their type, describe the marginal ridge as existing only 
on one side of the patch, the redness diffusing itself gradually in the 
rest of its circumference. The eruption may occur upon all parts of 
the body, but is most frequently seen on the trunk, particularly in 
the loins, and on the outer sides of the limbs. Its duration depends 
on the nature of the disease which it accompanies ; it generally ex- 
tends to several weeks. 

ERYTHEMA LiEVE. 
Erythema czdemalosum. 

Erythema lseve is an inflammation of the skin associated with 
oedema, and appearing for the most part in the lower extremities. 
When, however, the vital powers of the system are reduced, it may 



120 DISEASES ARISING FROM GENERAL CAUSES. 

be developed in any dependent part of the body. In the lower limbs 
it commences around the ankles by several small spots, which, by 
their increase, speedily form a patch of considerable extent. The 
inflamed surface is smooth, shining, and of a bright red color ; it is 
more or less swollen from distension of the subcutaneous cellular 
tissue with serous fluid, and is attended with itching, and by a painful 
sensation of tension. When left to itself, oedematous erythema may 
continue without change for several weeks, and may terminate even- 
tually in ulceration or mortification. When it issues in resolution, 
the swelling subsides, although the oedema may still remain for some 
time longer ; the brighter hue of redness merges into a purplish and 
livid tint, and the skin is long before it regains its natural appear- 
ance. Moreover, the epidermis desquamates in thin lamella. 

There is a form of erythema lseve which is very common in persons 
beyond middle life, and which affects the legs, extending from the 
instep and ankle to the hollow below the knee. The legs are more 
or less swollen, they pit on pressure, the oedema being greatest around 
their lower part ; they are hot, painful, itchy, particularly in the 
evening and in bed, and they are more or less reddened by a patchy 
and irregular redness. In this particular, also, there is a good deal of 
variety ; sometimes the redness is general and vivid, and at other 
times hardly discernible. In either case, if the skin be closely 
examined, it will be found to have the appearance of being cracked 
all over, which is really the fact. From the distension which has 
taken place, the cuticle has given way, and the derma, corresponding 
with the lines of rupture, looks red and angry, and forms a network 
of rough, more or less raised lines over the affected skin. The small 
islets of unbroken skin between the lines are more or less smooth, 
but sometimes roughened by exfoliation of the cuticle from their 
surface. Their edges, corresponding with the line of ruptured cuticle, 
are also rough, and in some instances their appearance is such as to 
suggest a comparison with the scaly integument of a serpent. 

Not unfrequently, there is an oozing of an ichorous fluid from the 
inflamed lines ; in which case the secretion dries, and forms a thin 
crust, and the eruption might be mistaken for eczema. At other 
times the inflamed lines have a papular character, and the case might 
be considered to be one of lichen. This form of erythema laeve is 
often troublesome and tedious, equally annoying to the patient and 
to his physician. 

In young persons, erythema lseve is an occasional result of sedentary 
habits, or of fatiguing exertion in close apartments. Those of the 
lymphatic temperament are most liable to its attack, and it is not 
unfrequently observed in chlorosis. In adults it sometimes appears 
without any more obvious cause than disorder of the digestive system, 
particularly in persons of intemperate habits. In persons of advanced 
life the affection is by no means uncommon, and occurs as a conse- 
quence of over-exertion in standing or walking. It is also a frequent 
complication of the oedema which accompanies varicose veins and 
anasarca. The local affection is usually accompanied by slight febrile 
symptoms, and by some degree of constitutional disorder. 



ERYTHEMATOUS OR EX ANTHEM ATO U S ERUPTIONS. 121 

Besides the erythema oedematosum now described, which results 
from a pre-existing oedema, and is found in a dependent part of the 
body, an cedematous erythema is sometimes met with around the 
eyes. This form of eruption commonly occurs in persons beyond 
the mid-period of life, and more frequently in women than in men : 
the oedema is not, as in the former case, the predisposing cause of the 
inflammatory congestion, but a consequence of that action operating 
on a tissue prone to serous infiltration. Not unfrequently it is met 
with in association with eczema existing in other parts of the body, 
or it occurs in persons who have previously suffered from eczema, 
and may itself be regarded as a stage of the latter disease. Moreover, 
it is apt to be taken for erysipelas, and, as far as external appearances 
are concerned, it closely resembles that affection, differing from it only 
in the lesser degree of constitutional disturbance. Under these cir- 
cumstances, erythema oedematosum is often considered and treated as 
an erysipelas, and is constantly spoken of by those who have suffered 
from its attack as being that disease. 

t 

ERYTHEMA INTERTRIGO. 

Erythema intertrigo 1 is that form of cutaneous inflammation which 
is induced by chafing the skin, either by the friction of one surface 
of the integument against another, by the friction or pressure of dress, 
by the irritation of secretions and discharges flowing over the surface, 
or by the presence of any cause of irritation whatever, as over-disten- 
sion of the skin, eruptive affections, &c. This inflammation is attended 
with little or no swelling ; but when it occupies the folds of the skin, 
whence the perspiratory fluid does not easily escape, or is produced 
by contact of secretions, the abraded derma pours out a sero-purulent 
ichor, which excites a troublesome itching. If the cause of irritation 
continue for some time the skin becomes excoriated, and deeply 
chapped. The cutaneous inflammation produced by pressure on the 
skin, as in bed-sores, is termed erythema paratrimma. 

Erythema intertrigo, from the friction of adjoining surfaces, is met 
with between the folds of the skin of infants, as between the buttocks, 
between the thighs, around the umbilicus, and in the groins, particu- 
larly if the parts be moistened by secretions, or unprotected by clean- 
liness ; in the folds of the skin of fat persons, especially in warm 
weather ; upon the face, from the overflow of tears, the saliva, or the 
secretion of the nose ; upon the vulva, the prepuce, and the scrotum, 
around the anus, and between the toes. When the disease occurs 
around the anus, it gives rise to pain during the action of the bowels, 
and frequently to spasm of the sphincter. In a case for which I was 
lately consulted, where the disease affected the prepuce, the aperture 
of this part was so much contracted and hardened by the cicatrices 
following upon chaps, that not only had phymosis resulted, but the 
urethra was also obstructed. 

1 Intertrigo, a chafe-gall, a fret. 



122 DISEASES ARISING FROM GENERAL CAUSES. 



ERYTHEMA PAPULATUM. 

Erythema papulatum (Plate I., Gr.) is characterized by the develop- 
ment of numerous small red spots, of which the largest scarcely exceed 
the disk of a split pea. They are accompanied by considerable itch- 
ing and tingling of the skin, which is increased after meals and during 
the night. On their first eruption the spots are of a bright red color, 
and slightly raised above the surface of the surrounding skin. The 
swelling, however, subsides in the course of a few days, but the red- 
ness continues for one or two weeks, becoming purplish in its tint, 
and yellowish as it fades away. In distribution the spots are irregu- 
lar, being in some situations aggregated into thickly-set patched, 
while in others they are scattered and dispersed. This variety of 
erythema occurs most frequently on the face and neck, chest, arms, 
backs of the hands and fingers. It is met with at all periods of life, 
particularly in young persons and females, is preceded by febrile 
symptoms, and is usually associated with irritation of the gastro-pul- 
monary mucous membrane, and sometimes with rheumatism. 

ERYTHEMA TUBEROSUM. 

Erythema tuberosum (Plate I., H.) consists of an eruption of 
patches of a circular form, and of a size varying between a four-penny- 
piece and a shilling. They are frequently interspersed among the 
smaller spots of erythema papulatum, on the upper parts of the body; 
but upon the legs, where the eruption is most frequent, they occur 
without admixture. Like erythema papulatum, the spots are pre- 
ceded by itching and tingling; they appear generally at night, are 
brightly red and very tender at their first outbreak, become purplish 
in the course of two or three days, and assume the yellow and green- 
ish tint of a bruise as they subside. The eruption is frequently 
ushered in with chills and feverish symptoms, and is accompanied in 
its course by debility, languor, and considerable constitutional dis- 
turbance. This form of erythema is frequently met with in female 
servants, particularly in those who have been recently transferred 
from the fresh air of the country to the confinement of London kitch- 
ens. It is seen also in persons of debilitated constitution, and, accord- 
ing to Dr. Corfe, is generally associated with disordered menstrual 
function. 

ERYTHEMA NODOSUM. 

Erythema nodosum (Plate L, i) is an inflammation of the skin 
occurring in oval patches, which vary in size, from half an inch to two 
or three inches in diameter, and are situated for the most part on the 
upper and lower extremities. The long diameter of the patch usually 
corresponds with that of the limb, but in several instances I have seen 
it occupy the opposite position, and two patches, one before and one 
behind, meeting by their extremities, have surrounded the leg as with 
a bracelet. The oval patches are slightly raised above the surround- 
ing surface, the elevation increasing gradually towards the centre ; 



ERYTHEMATOUS OR EX ANTH EM AT U S ERUPTIONS. 123 

they are hot, painful, and tender ; of a bright red color at their erup- 
tion, but change in the course of a few days to a purplish and livid 
tint, which becomes subsequently yellow and greenish, and has the 
appearance of an ordinary bruise. The inflammatory activity of the 
patches increases for several days, during which they are hard and 
painful ; they then become softer to the touch, and by the eighth or 
tenth day have nearly subsided ; terminating by a transient discolor- 
ation of the skin, and desquamation of the epidermis. Erythema 
nodosum is preceded by symptoms of general feverishness, such as 
headache, languor, chills, dry skin, quick pulse, white tongue, nausea, 
diminished secretions, &c, and disturbance of the digestive organs ; 
these symptoms diminishing on the appearance of the eruption. It 
has also been observed in connection with rheumatism ; it attacks 
chiefly young persons and females, and those of a debilitated habit of 
body. 

Erythema papulatum, tuberosum, and nodosum, are so closely allied 
to each other, that they might with advantage be included under the 
same name. The two former are commonly associated in the same 
patient, and I have more than once seen erythema papulatum on the 
face and hands, while erythema nodosum existed on the legs. 

ERYTHEMA CHRONICUM. 

The term chronic has reference to two states of erythema, namely, 
that in which the erythematous blush is from the beginning slow in its 
progress, subsequently stationary, and does not aifect the integrity of 
the skin ; and that which represents the advanced stage of an acute 
erythema, wherein the erythema, instead of terminating by resolution, 
becomes, as it were, permanently established in the skin, assumes new 
characters, and persists for an indefinite length of time. 

Of the former kind, namely, slow in progress, and subsequently station- 
ary, are the red patches called fiery spots, that are frequently seen upon 
the face ; which vary in brightness with the health of the patient, and 
are especially vivid after meals. 

Of the latter kind, namely, those which represent a persistent stage of 
erythema, are patches of erythema commonly found among the folds of 
the skin, in the flexures of joints, behind the ears, upon and around the 
lips, around the nipples, in the perinaeum, in the groins, around, the vari- 
ous apertures of the body, and upon the scalp. In this form of erythema, 
there is besides the redness of the skin, more or less thickening of the 
derma, more or less exfoliation of the epidermis, and sometimes cracks 
and chaps of the skin. This form of erythema is very commonly met 
with as a sequel of chronic lichen and chronic eczema ; a chronic lichen, 
in fact, wherein the papulae have subsided, or a chronic eczema in 
which the ichorous secretion has ceased to be formed, the redness, the 
thickening of the skin, and more or less of exfoliation of the epidermis 
remaining; in a word, the pathological state of the skin to which the 
term psoriasis has been applied,. and to which it should be strictly 
limited. 

Psoriasis, therefore, is nothing more than a chronic erythema; and 



124 DISEASES ARISING FROM GENERAL CAUSES. 

as this form of erythema is more frequently a sequela of lichen and 
eczema, most commonly of the latter, than of common erythema, I 
have made its description follow that of chronic eczema. 

Another form of chronic eczema, sometimes appertaining to the 
first, and sometimes to the second class, but more properly belonging 
to the former, remains, however, to be described. It is characterized 
by an erythematous blush of the skin, circumscribed, of a more or less 
circular figure, and covered by a furfuraceous, or more frequently by 
a mealy desquamation of the epidermis. This is the eruption which 
has been denominated pityriasis. In the dermatographic classification 
of cutaneous diseases, pityriasis is associated with psoriasis, and both 
are described in companionship with lepra, simply from the circum- 
stance of presenting a surface coated with minute scales. Psoriasis, 
moreover, is confounded with lepra ; but these diseases have nothing 
in common with lepra, further than some slight similarity of appear- 
ance. 

ERYTHEMA PITYRIASIS. 

Syn. Lepidosis pityriasis ; Mason Good. Dartre furfur acee ; Alibert. — 
Sehuppen, Germ. Dandruff. Branny tetter. 

Erythema pityriasis 1 (Plate XII., L.) is a chronic inflammation of 
the skin, which is characterized by the production of minute white 
scales in great abundance, on patches of irregular form, and variable 
dimensions. The patches are of a dull red or pinkish color, but some- 
times so light as scarcely to be distinguishable from the surrounding 
skin. They are developed on any part of the body, frequently in suc- 
cession, and are attended with heat, and some degree of pruritus and 
tingling. The scales are thrown off as soon as formed, and are repro- 
duced with great rapidity ; they are for the most part small and mica- 
ceous ; in certain situations, however, where 'the integument is thick, 
they are larger and furfuraceous, and in those parts where the integu- 
ment is thin, as in the flexures of joints, are pulverulent and mealy. 
Pityriasis, from its chronic nature, is a disease of long continuance, 
but is not contagious. 

The varieties presented by pityriasis are distinguishable into general 
and local ; of the former, "WTllan enumerated three, and of the latter, 
one. The general varieties of Willan are, pityriasis rubra, pityriasis 
versicolor, and pityriasis nigra ; the first of these alone deserves to be 
considered as an erythema ; the other two are chiefly remarkable for 
their alteration of color, and are consequently referable to the chro- 
matogcnous disorders. The local variety indicated by Willan is 
pityriasis capitis ; to which Rayer has added pityriasis palpebrarum, 
labiorum, palmaris et plantaris, prseputialis, pudendalis, and pityriasis 
oris. The whole of these so-called varieties of pityriasis are clearly 
nothing more than chronic erythema, verging more or less on psori- 
asis. 

1 Der. vivvpov, furfur, bran, from the bran-like desquamation by which it is attended. 



ERYTHEMATOUS OR E X ANTHEM AT US ERUPTIONS. 125 

PITYRIASIS VULGARIS. 
Syn. Pityriasis rubra, Willan. 

Pityriasis vulgaris (Plate XII., F.) occurs indiscriminately upon any 
part of the body, but particularly in the flexures of the skin, and on 
those regions which are exposed to the influence of the air, as the 
face, neck, and hands. It is distinguished by the eruption of red 
superficial patches, upon which the scales are produced, at first in 
small number, so as to give rise to some degree of roughness only, 
but subsequently in large quantities. This affection is very com- 
monly met with in children and persons possessing a delicate skin 
and fair complexion, upon the sides of the chin, around the mouth, 
and on the forehead. When of considerable extent, pityriasis is 
attended with itching and tingling, more particularly at bedtime, and 
during the night. By successive eruption on different parts of the 
body, the disease may gradually extend over the entire cutaneous 
surface, disappearing in some parts, while it breaks forth in others. 
In this manner it is frequently prolonged for months, and is very 
obstinate ; the subcutaneous cellular tissue sometimes becomes thick- 
ened and infiltrated ; and if the surface be abraded by scratching, an 
ichorous fluid is poured out (eczema), which desiccates into thin 
scabs, and complicates the diagnosis of the disease. After the decline 
of pityriasis, the skin presents for some time a yellowish stain. When 
the disease is general, or a large surface of the body is implicated, 
the eruption is accompanied with languor and slight constitutional 
disturbance. 

PITYRIASIS CAPITIS. 

Syn. Dandruff. 

Pityriasis capitis appears upon the head chiefly in children and old 
persons, commencing usually upon the temples, and around the fore- 
head, and thence extending to the rest of the scalp. It is a trouble- 
some affection, attended with much itching, and, at its first invasion, 
with some degree of redness, which gradually disappears, and leaves 
the integument whiter than its natural hue. Occasionally it extends 
to the eyebrows, the whiskers, and the beard. Pityriasis may continue 
for months, and even for years, particularly in old persons, but is per- 
fectly amenable to treatment. 

Diagnosis. — The diagnostic characters of erythema are, redness 
and heat of skin with but trifling swelling, the redness passing by 
degrees into a purple and livid tint, as the inflammatory excitement 
subsides. The absence of tumefaction, and distension of the subcu- 
taneous cellular tissue, at once distinguish erythema from erysipelas. 1 

Erythema fugax (E. volaticum genarum) is distinguished from the 
other varieties principally by negative characters, namely, by the 

1 Plenck's definition of erythema is as follows: "Macula rubra, solitaria, apyreta, et 
topica." 



126 DISEASES ARISING FEOM GENERAL CAUSES. 

absence of those peculiarities which mark the rest. The redness is 
diffused, there is little swelling, the surface is dry and hot, and the 
inflammation evanescent. 

Er} r thema circinatum is remarkable for the annular form of its 
patches ; it is distinguished from herpes circinatus by the absence of 
vesicles, and from lepra in progress of cure by its general appearance, 
and by the previous history of the affection. 

Erythema marginatum is recognized at an early stage by the annu- 
lar form of the patches, and, at a later period, by its abrupt and papu- 
lated border. 

Erythema laave is characterized by its association with oedema of 
the subcutaneous cellular tissue. 

Erythema intertrigo is distinguished from eczema by the absence 
of vesicles. The cause of intertrigo, again, is immediately obvious 
(E. ab applicatis acribus ; E. a decubitu ; E. ab attritu ; rubedo clu- 
nium in equitantibus). 

Erythema papulatum may be confounded with some forms of rose- 
ola, from which it differs but little, and particularly with urticaria ; 
but the latter is more irregular and unsteady in its progress, and the 
itching is more pungent. 

Erythema tuberculatum is distinguished by the circular red patches 
developed on the skin, and by the constitutional symptoms. 

Erythema nodosum is so clearly characterized, as to offer little room 
for confounding it with any other eruption. Roseola is that which 
approaches it most nearly. Erythema nodosum is distinguished from 
other cutaneous affections by the oval form of the patches, and by 
their general erythematous characters. It differs from roseola in the 
greater depth of its inflammation. 

Erythema chronicum may be known by its general characters ; the 
furfuraceous and mealy desquamation determining the forms which 
belong to pityriasis, and the remains of papulae, or some degree of 
ichorous discharge, the sequelae of chronic lichen or chronic eczema. 

Causes. — The proximate cause of erythema is congestion of the 
vascular rete of the derma, induced by local or by general causes. 
The varieties coming under each of these heads have been already 
specified. Erythema may also be induced by disorder of the digestive 
organs, from the use of improper food, or from taking irritating mat- 
ters into the stomach, as copaiba. The peculiarities of color observed 
in the disease under consideration are explained by reference to the 
general principles of inflammation. During the period of excitement 
the blood is of a bright red color; it courses rapidly through the part, 
and the vessels become dilated. After the subsidence of the excita- 
tion, the stream of blood flows languidly through the dilated vessels, 
and assumes the venous character in its course. Hence the bright 
red tint of the early periods of erythema, and its purplish and livid 
hue during the subsequent stages. 

The exciting causes of erythema laeve are, retarded venous circula- 
tion through the limb, and interference with the vascular distribution 
in the skin by ocdematous distension of the subcutaneous cellular 
tissue, while its predisposing cause is very commonly, gout. 



ERYTHEMATOUS OR EX ANTHEM ATO U S ERUPTIONS. 127 

Prognosis. — Erythema is for the most part a slight affection, and 
derives its chief importance from the disease with which it may chance 
to be associated, or from the nature of its cause. The duration of the 
acute varieties rarely extends to more than two or three weeks. 
Chronic erythema speedily yields when the exciting cause is removed, 
and erythema lseve, the most serious of the erythematous inflamma- 
tions when it occurs in old persons, is easily controlled by judicious 
treatment. 

Treatment. — The principles of treatment of erythema resolve 
themselves into three indications : 1. To restore the altered functions 
of the system to healthy action. 2. To allay the local irritation. 3. 
To excite the nerves of the part to resume their normal tone, and the 
congested vessels their normal dimensions and functions. 

The symptomatic varieties of erythema require to be treated through 
the disease upon which they are dependent. The method of treat- 
ment must consequently vary in relation to circumstances. In some 
instances, the antiphlogistic plan may be required, in others, the irri- 
tation of mucous tissues must be soothed, while in others, again, it 
may be necessary to excite counter-irritation at a distant part. With 
the latter view, aloes combined with myrrh will be found a useful 
remedy, particularly in females. . 

When the system is reduced, and the powers are enfeebled, tonic 
remedies are indicated ; bitters combined with acids are of great ser- 
vice, together with an appropriate regimen and the judicious use of 
exercise ; after a course of these remedies, Fowler's solution may be 
commenced, in doses of three or four minims three times a day, either 
directly after or with meals. In chronic erythema arsenic is especially 
indicated. 

Sponging the entire surface of the body with tepid water and soap 
every day, or every other day, with occasional tepid baths, and drying 
the skin thoroughly with a towel, will also be found useful. To this 
means may frequently be added, with great advantage, the friction on 
the unaffected skin of some stimulant spirit or liniment, such as a 
drachm of tincture of croton, 1 combined with one ounce of spirit of 
rosemary and three of rose-water ; or two drachms of liquor ammonise 
fortior to aqua calcis and oleum olivse optatum, two ounces each. 

The local treatment should, according to circumstances, consist in 
evaporating lotions, water-dressing, or warm fomentations. In the 
erythema i'ugax of the face and neck, the benzoated zinc ointment 
with spirits of wine will be found a grateful application. 

For erythema \save, the general treatment must consist in the 
restoration of the secretions, in establishing the regularity of the 
digestive organs, and in the subsequent exhibition of tonics, with at- 
tention to diet. Where gout is suspected to-be the cause of the dis- 
ease, ;t warm antacid purgative, sucli as Gregory's powder, or a powder 
composed of rhubarb, soda, and calumba, with or without colchicum 

1 The tincture of croton, a most valuable cutaneous stimulant, is made by adding four 
Onncee of spirit of wine to one ounce of the bruised seeds of croton. It is ready for use 
at the end of a week. 



128 DISEASES ARISING FROM GENERAL CAUSES. 

or iodide of potassium, should be given twice or three times a day, 
and the juice of two or three lemons as a cooling drink. The local 
treatment demands rest, such a position of the limb as will assist the 
venous circulation as much as possible ; evaporating lotions or warm 
fomentations in the acute stage, succeeded, as soon as the inflamma- 
tion has somewhat subsided, by inunction with the ceratum plumbi, 
or the oxide of zinc ointment, either alone or in combination with the 
liquor plumbi diacetatis, or spirits of wine, and by the application of 
a well-adjusted cotton bandage. Gentle frictions with camphorated 
spirit may be employed when the local excitement is reduced, and 
repeated night and morning at each application of a fresh bandage. 
The erythema accompanying anasarca is immediately relieved by 
position. 

The excoriations of erythema intertrigo require to be kept perfectly 
clean, and free from the original cause of irritation. They should 
then be dusted with some absorbent powder, such as Fuller's earth, 
starch powder, oxide of zinc, &c, or anointed with the oxide of zinc 
ointment. Erythema paratrimma is best treated by the oxide of zinc 
ointment, or by soap plaster spread upon wash-leather. In erythema 
a decubitu, or bed-sore, the inflamed skin should be painted with a 
liniment of white of egg and spirit of wine, arid afterwards covered 
with soap plaster spread on amadou. 

Erythema papulatum, tuberosum, and nodosum, require antiphlo- 
gistic regimen, a brisk purgative of calomel and colocynth at the com- 
mencement, then tonics and the mineral acids. 

Chronic erythemata are to be managed according to the general 
principles of treatment above detailed ; the excitement of the affected 
part is to be reduced in the first instance by soothing applications, 
and then astringents and gentle stimulants are to be used. The chap- 
ping of the hands may be prevented and relieved by the use of a 
small quantity of honey, which should be rubbed into the inflamed 
part each time the hands have been washed, and then wiped off, so as 
to remove any stickiness that may remain. Glycerine may be applied 
in the same way, or an ointment of oxide of zinc may be found useful 
for the same purpose. 

Erythema or pityriasis capitis, invariably yields to an application 
composed of one part of the red precipitate ointment to three of lard ; 
or to the white precipitate ointment diluted in the same proportion. 

Erythema of the nipples (chapped nipples) is best relieved by the 
application of the oxide of zinc ointment made into a cream with 
spirits of wine or spirits of camphor, an ointment of nitrate of silver, 
containing from five to ten grains to the ounce ; the tinctures, of kino 
and catechu ; infusion of oak bark or pomegranate ; or lotion of 
chloride of lime. Other useful applications for chapped nipples are 
— a powder consisting of equal parts of borax and powder of acacia, 
which should be dusted frequently upon the cracks and excoriated 
surface ; and mucilage of gum acacia. The latter should be pencilled 
on the tender part immediately after suckling, and the nipple protected 
with a leaden shield or limpet shell. I have also seen great benefit 
result from the use of collodion, which, judiciously applied, and 



ERYTHEMATOUS R E X AN TH E M AT U S ERUPTIONS. 129 

assisted by other means, will be found a valuable remedy. Collodion 
is a good defensive agent for protecting the tender skin from the 
effects of pressure and moisture. 

It is judicious, in most cases, to wean the infant when the nipples 
are tender and chapped ; but when weaning is objected to or incon- 
venient, a shield and teat should be applied, without interfering with 
the zinc or nitrate of silver ointment. 

For erythema of the vulva and anus, the most soothing applications 
are, the superacetate of lead ointment, or the oxide of zinc ointment 
with liquor plumbi diacetatis. Over these an evaporating lotion may 
be used, if requisite ; and when the acute stage is passed, the milder 
ointments may be replaced by the nitrate of mercury ointment, more 
or less diluted, as the feelings of the patient may permit. The nitrate 
of silver ointment and juniper tar ointment are also found to be of 
service in some instances. 

Cases Illustrative of Erythema. 

Erythema papulatum. — A married lady, habitually dyspeptic, became 
overheated on the 16th of December, 1845 ; she was afterwards chilled 
by exposure to cold in an open carriage for some hours. At night she 
was feverish and restless. 

Dec. 17. Next day she felt unwell, with general malaise and lassi- 
tude, was exposed to cold as before. In the afternoon had nausea and 
chills. At dinner she partook of boiled beef, at all times an unpala- 
table dish to her, and suffered in the evening from nausea and head- 
ache. In the night she was awakened with intense nausea, but had 
no vomiting. 

18th. Third day. Felt very unwell, nausea still continuing with 
lassitude. A punctiform rash became perceptible on the backs of her 
hands and fingers ; the rash was more vivid at night, and attended 
with considerable itching. 

19th. Eruption increasing; affecting the elbows as well as the hands, 
and slightly the neck and face. 

22d. Seventh day. Eruption at its height. On the elbows, the 
papulae formed a patch of about the size of the palm of the hand ; 
they were numerous on the fingers and backs of the hands, and few 
anil scattered on the face, neck, and head. The greater number of the 
papulae were hemispheroidal, slightly raised, of a vivid red color, and 
equal in size to a split pea. Some were clustered into circular and oval 
groups of the size of a sixpence, and others were single and isolated. 
On the backs of the hands were spots of a larger size than those above 
mentioned, as large in diameter as a sixpence or shilling (erythema 
tuberosum) ; they increased in breadth by their border, which was 
prominent and papular, while the included area became pale and 
yellowish. The eruption was very tender to the touch. 

23d. Eighth day. The symptoms of nausea and feverishness, which 
were slightly diminished on the appearance of the eruption, were 
now greatly relieved. The eruption was on the decline ; the tender- 
ness subsided ; the redness diminished ; and each little papula, as it 

9 



130 DISEASES ARISING FROM GENERAL CAUSES. 

gradually disappeared, formed a distinct ring of red, with a light 
yellowish area. Traces of the eruption lasted until the end of the 
second week. 

Erythema papulatum et nodosum. — A widow, forty-five years of age, 
regular, had been suffering four months with bronchitis. On the 1st 
of April, 1846, she had an eruption on the face, and then on the 
hands, of papulre of a bright red color, and accompanied by severe 
itching and tingling. These symptoms were increased on taking 
fluids of any kind, particularly such as were warm, and they were 
greatly augmented by the warmth of bed. The papulae were very 
tender to the touch, particularly around the finger nails. A few days 
after the disappearance of the eruption on the face, the large, oval- 
shaped swelling (delineated in Plate VII.) made its appearance, at- 
tained its height on the second day, and declined on the fourth, 
leaving behind it a purplish and yellow stain, like that of a bruise. 
The constitutional symptoms preceding and accompanying this erup- 
tion were nausea, feverishness, and extreme lassitude. The languor, 
with great depression of spirits, continued until the termination of the 
disease. 

Erythema tuberosum. — A young woman, aged twenty-two, enjoyed 
good health until nine months ago, when she obtained service in Lon- 
don as housemaid. Since that period she has suffered constant illness ; 
sometimes her bowels were constipated, sometimes she had nausea, at 
other times cough ; menstruation was disturbed, becoming scanty and 
light-colored ; she had leucorrhoea, and copious deposits in her urine, 
with difficulty in passing it. In fact, all the mucous membranes in 
her body suffered more or less from disorder. Associated with these 
symptoms, she had a constant feeling of languor, loss of appetite, and 
indisposition to make any exertion. While in this state she was seized 
(January, 1846) with a dry, hard cough, accompanied with headache 
and the usual train of febrile symptoms ; and a copious eruption of 
erythema tuberosum made its appearance on her forearms, knees, and 
legs. The majority of the spots were of the size of a shilling piece, 
they were distributed regularly over the skin, and were very tender to 
the touch. On their first appearance they were vividly red, but soon 
became purplish and yellowish, and by the third or fourth day, were 
on the decline. This patient recovered at the end of three weeks ; her 
treatment consisting in a smart purgative at first, followed by tonics 
and wine, and an occasional warm bath during her illness. Water- 
dressing was used to the eruption. 

Erythema la>ve of the ankle. — A cook, forty years of age, after a 
week of unusual exertion, felt languid and ill, and was unable to walk, 
in consequence of pain and swelling in her right leg. Her pulse was 
quick, she had a, dry, furred tongue, and headache. The affected leg 
was oedematous, particularly around the ankle. In the latter situation 
there was a broad and extensive patch of erythema lgeve. The veins 
of both limbs were varicose, but she had never before suffered from 
any affection of the legs. I ordered her to bed, gave her an active 
purgative with salines, had the leg supported on an inclined plane, the 
inflamed parts wetted with a layer of lint dipped in a saturnine and 



ERYTHEMATOUS OR EX ANTHE M ATO US ERUPTIONS. 131 

alcoholic lotion, and the whole of the lower leg enveloped in oiled 
silk. By the next morning the redness had diminished very consider- 
ably, and the oedema was much reduced. I then moistened the limb 
with camphorated spirit, and bandaged it firmly, from the foot up- 
wards, to the lower part of the thigh, readjusting the bandage night 
and morning. From the first day of the application of the bandage 
she was enabled to walk, but in consequence of again over-exerting 
herself, and misapplying the bandage, which, after the first few days, 
I intrusted to herself, it was found necessary to confine her again to 
bed, where in a short time she recovered. 

Severe erythema Iceve of both leg.?. — In the autumn of 1841 I was 
called, with my friend, Mr. Coulson, to see a lady of advanced age, 
aifected with this disease. She was corpulent, of sedentary habits, 
had long suffered from oedema, and her present attack had lasted for 
several weeks, resisting the various modes of treatment which had 
been pursued. The skin of the entire surface of both legs was of 
a deep red tint, highly congested, and covered with a rough and ex- 
foliating epidermis. Her tongue was foul, and her general health very 
much disturbed, so much so, indeed, that she was apprehensive for her 
life. For the purpose of relieving the congested state of the skin, we 
recommended free scarification with the point of a lancet, to be fol- 
lowed by fomentation and bandaging. To this, however, she objected. 
We then ordered strict attention to position, painting the surface with 
the tincture of iodine, and carefully adjusted compression by means 
of strips of soap plaster spread upon leather ; the local treatment being 
assisted by an occasional aperient and tonics. In the course of a few 
weeks she had entirely recovered. 

Erythema Iceve, issuing in mortification and death. — An aged woman 
complained of great pain and uneasiness in the left foot and ankle. 
There was a diffused patch of redness, with slight oedema, occupying 
the front of the ankle and the dorsum'of the foot. Her tongue was 
not much altered, but her pulse was quick. I directed her to remain 
in bed, and to apply fomentations to the limb, at the same time 
recommending her to the attention of a neighboring medical friend. 
In a few days the part became discolored, and sphacelus commenced, 
which extended rapidly up the limb as far as the groin. After death 
the whole of the arteries of the limb were found to be solidified by 
calcareous depositions, and some of the smaller vessels were completely 
obstructed. 

ERYSIPELAS. 

Syn. Erythema Erysipelatosum ; Mason Good. Rosa. Ignis Sacer. Ignis 
Sancti Anthonii. Erysipele, Fran. Motheauf, Germ. 

Erysipelas 1 is a diffused inflammation of the skin and subcutaneous 
cellular tissue, affecting a part of the surface of the body, and accom- 
panied by fever. The local inflammation has a special disposition to 
spread; it is attended with swelling, a pungent, burning, and tingling 
heat, and by a redness which disappears under pressure with the 

1 Der. igeuflo?. rubor. 



132 DISEASES ARISING FROM GENERAL CAUSES. 

finger, to return so soon as the pressure is remitted. It is often accom- 
panied by vesications containing a limpid amber-colored serum, which 
quickly burst, and form thin, dark-colored crusts. Erysipelas termi- 
nates generally in resolution with desquamation of the epidermis, some- 
times in delitescence, or suppuration, and more rarely in mortification. 
Erysipelas admits of division into two principal varieties, erysipelas 
simplex, and erysipelas phlegmonodes. The former of these possesses 
several sub-varietie's, and some local forms deserving of attention 
from the modifications which they present, these modifications being 
a consequence of the peculiarities of the region in which they are 
developed. Erysipelas phlegmonodes offers but one sub-variety of 
importance. The varieties and sub-varieties of erysipelas may be 
thus arranged : 

ERYSIPELAS SIMPLEX. 

Sub-varieties. Local sub-varieties. 

Erysipelas erraticum, Erysipelas faciei, 
" metastaticum, " capitis, 

" miliare, " mammae, 

" phlyctenodes, " umbilicale. 

" cedematodes. 

ERYSIPELAS PHLEGMONODES. 

Sub-variety. 
Erysipelas gangrenosum. 

ERYSIPELAS SIMPLEX. 

Syn. Febris Urysipelatosa ; Sydenham. 

The inflammation of erysipelas always extends more or less deeply 
into the tegumentary textures*. That which affects the skin the most 
superficially, is the form at present under consideration, which would 
seem to be limited to the derma and its immediately contiguous 
cellular tissue. Simple erysipelas occurs most frequently upon the 
face and head, next in frequency upon the limbs, and most rarely on 
the trunk of the body. Like other cutaneous diseases, it offers for 
inquiry, in the first place, its general or constitutional, and, in the 
second, its local symptoms. 

The constitutional symptoms of idiopathic erysipelas are, — chilliness 
and rigors, succeeded by flushes of heat ; dejection of spirits, lassitude, 
pains in the back and limbs, pains in the head, drowsiness ; quick 
and hard pulse; thirst, loss of appetite, white and coated tongue, 
bitterness of mouth, nausea, vomiting, pain at the epigastrium, and 
constipation. These, or some of these symptoms, and in greater or 
less degree, precede the local disorder for several days, increasing with 
the progress of the efflorescence, and disappearing at its decline. 
During the height of the local inflammation the affection of the 
nervous system often becomes exceedingly severe ; there is low, mut- 
tering delirium, with subsultus tendinum, an exceedingly rapid pulse, 
and a brown and dry tongue. At the close of the fever there is • 



ERYTHEMATOUS OR EX A NTHE M ATO U S ERUPTIONS. 133 

commonly a critical relaxation of the bowels, a sediment in the urine, 
and occasionally a slight hemorrhage from some part of the gastro- 
pulmonary mucous membrane, or from the uterus. 

Simon observes, that in the early stage of erysipelas the urine puts 
on the inflammatory character. " It is frequently," Schonlein remarks, 
"loaded with bile-pigment, and is of a reddish-brown or red color. 
At the urinary crisis, fawn-colored precipitates are deposited, and the 
urine becomes clear." Becquerel made two quantitative analyses of 
the urine of a man, thirty-nine years of age, who had erysipelas of the 
face and a good deal of fever, his pulse being 112. The urine of the 
first analysis was of a deep yellowish red color, and clear ; its specific 
gravity was 1.021. That of the second was so deeply colored, as to 
appear almost black ; it threw down a reddish sediment of uric acid, 
and had a specific gravity of 1.023. The first analysis was made 
on the fourth, and the second on the sixth day of the fever. The 
analyses are as follows: Becquerel's analysis of healthy urine being 
placed for comparison in a third column : 

Anal. 1. Anal. 2. Health. 

Ounces of urine in 24 hours, . . 27.0 ... 30.8 — 45.0 

Water, 965.5 ... 961.9 — 972.0 

Solid constituents, .... 34.5 ... 38.1 — 28.0 

Urea, 12.5 ... 12.7 — 12.1 

Uric acid, . . . . 1.2 ... 1.3 — 0.4 

Fixed salts, . . . . — ... 8.2 — 6.9 

Extractive matter, . . . — ... 15.9 — 8.6 

Specific gravity, .... 1021.0 —1023.1 —1017.0 

"In a woman, aged forty-five years, with erysipelas of the face, 
whose pulse was 104 and full, the urine was very scanty, of a dark 
brown color, strongly acid, threw down a yellow sediment sponta- 
neously, and had a specific gravity of 1023.1. It contained — 

Water, 961.7 

Solid constituents, ....... 38.3 

Urea, 11.7 

Uric acid, . . . . . . . 1.3 

Fixed salts, 9.2 

Extractive matters, 15.7 

"In five cases in which the morning urine was daily examined 
with care, the characters of inflammation were present in a very high 
degree; the specific gravity varied from 1021 to 1025. In four of 
these cases the urine threw down a reddish sediment, and in two a 
little albumen was occasionally present." 1 

The local affection makes its appearance on the second or third day 
from the commencement of the febrile symptoms, and is frequently 
accompanied by soreness of throat and congestion of the fauces. On 
the skin it appears as a somewhat swollen and irregularly circum- 
scribed yellowish red patch, which is accompanied by a painful 
sensation of tension, and by a sharp, burning, and tingling, or prick- 

1 Simon's Animal Chemistry, vol. ii. p. 278. 



134 DISEASES ARISING FROM GENERAL CAUSES. 

ling heat. On the third and fourth days the redness becomes more 
vivid, the tumefaction greater, and the painful sensations more acute. 
These symptoms continue without change until the sixth or seventh 
day, when they begin to decline. The redness then subsides, fading 
into a pale yellowish tint; the swelling diminishes, the epidermis is 
thrown into wrinkles, is dry and friable, and speedily desquamates in 
thin transparent scales. The resolution of erysipelas is the most 
favorable termination of the disease. 

Sub-varieties. 

Erysipelas erraticum. — Erysipelas is remarkably and characteristi- 
cally disposed to wander from the spot where it was first developed, 
to extend itself more diffusely, and to fix upon new situations. Some- 
times we find it simply spreading, and thus increasing in extent the 
inflamed surface; at other times it subsides entirely on the parts first 
affected, as it proceeds in its erratic course, or it suddenly quits its 
original situation to appear as suddenly on one more distant. This 
erratic or ambulant disposition of erysipelas is often seen upon the 
face and head, where it is exceedingly intractable. 

Erysipelas metastaticum. — This designation indicates a variety of 
erysipelas in which the efflorescence suddenly disappears on the sur- 
face of the body, and some internal organ becomes immediately and 
severely affected. The metastatic form of the disease occurs most 
commonly in debilitated and broken constitutions, and is particularly 
observable with regard to erysipelas of the head and face. The organs 
most liable to suffer from the metastatic action in erysipelas are the 
brain or its membranes, and the gastro-pulmonary mucous membrane. 
Metastasis to the membranes of the brain is accompanied by delirium 
and coma, and usually terminates fatally. Dr. Watson remarks that 
the metastasis of erysipelas is rare. " I do not recollect to have seen 
it. But the extension of the inflammation, the supervention of 
delirium and coma, while the external inflammation continues, is of 
common occurrence." 

Erysipelas miliare. — It occasionally happens that a crop of small 
vesicles [Erythema vesiculate, Mason Good), like those of eczema, 
make their appearance on the inflamed surface. They contain a 
limpid, serous fluid, burst in the course of a day or two from their 
eruption, and leave behind them small, brownish-colored scabs. 

Erysipelas phlyctenodes is a common form of the disease; it is that 
in which vesicles (Bulla*, Erysipelas bullosum) of considerable size, and 
irregular in their form, appear upon the inflamed skin. They usually 
arise on the fourth or fifth day, burst in the course of twenty-four 
hours from their development, and terminate by forming yellowish 
scabs, which gradually become brown, and afterwards black. The 
bullae contain a limpid serum, at first colorless, but changing by 
degrees to a pale straw or amber tint. Occasionally the fluid becomes 
opaque, and sometimes assumes a purplish hue; the latter is an 
unfavorable sign. 

Erysipelas oedematodes. — In persons of a lymphatic temperament, 



ERYTHEMATOUS OR E X A NT H E M AT U S ERUPTIONS. 135 

and in constitutions debilitated by previous disease or excess, there 
exists a disposition to the effusion of a serous fluid into the tissue of 
the derma and into the sub-dermal textures, constituting oedema. In 
this form of erysipelas [Erythema cedematosum, Mason Good) the 
inflamed surface is less brightly red than in the preceding varieties, 
the surface is smooth, tense, and shining, and a pale depression or pit 
is left upon the skin by the pressure of the finger. Erysipelas oedema- 
todes occurs most frequently in the lower extremities and external 
organs of generation, and terminates like the simple form of the 
disease, the effused fluid being removed by subsequent absorption. 

Local sub-varieties. 

Erysipelas of the face. — The face is the most frequent Seat of erysi- 
pelas. It commences usually on the side of the nose, and spreads 
rapidly over the -whole of one side of the face, extending sometimes 
to both. The face is so much swollen by the attack that the features 
are scarcely recognizable. The cheeks are enlarged, the eyelids 
turgid and infiltrated, and the lips tumid. The constitutional symp- 
toms accompanying the local disorder are exceedingly severe ; there is 
violent headache, sleeplessness, frightful dreams, and commonly 
delirium. The disease reaches its height on the fourth or fifth day, 
and terminates on the seventh or eighth. It is frequently accompanied 
by inflammation of the mucous membrane of the nose and mouth, by 
a swollen and painful state of the parotid glands, and its resolution is 
occasionally indicated by a critical hemorrhage from the pituitary 
membrane. Erysipelas" of the face is always serious, from the great 
liability to the occurrence of metastasis or extension to the brain, and,, 
it is frequently succeeded by subcutaneous abscesses and diffused 
suppuration ; the latter sequela is most commonly met with in the neck. 

When erysipelas of the head and face terminates fatally, death is 
usually occasioned by effusion Avithin the head, and coma. Another 
cause of death is apnoca, from infiltration of the submucous tissue of 
the glottis ; and a third, asthenia, or a total prostration of the vital 
powers. 1 

Erysipelas of the scalp is usually the consequence of a wound or 
injury of the head, and occurs in about a week or ten days from the 
reception of the violence. The affected integument is oedematous, 
smooth, shining, and very sensitive ; but the redness is more dull 
than in other situations. When left to itself, erysipelas in this region 
issues in suppuration and gangrene of the cellular and fibrous tissue 
of the scalp. It often terminates by metastasis, or rather by extension 
to the brain. 

Erysipelas of the mammal. — From the quantity of cellular substance 
surrouiM t i ii lt the mammary gland, erysipelas in this region is disposed 
to take on the phlegmonous character, and to terminate in extensive 
suppuration, and gangrene of the fibrous substance. The redness 
accompanying the exanthem is by no means vivid. 

1 Dr. Watson — Lectures. 



136 DISEASES ARISING FROM GENERAL CAUSES. 

Erysipelas of the umbilical region occurs in infants (erysipelas neon- 
atorum), particularly in public institutions, and is referable to irrita- 
tion produced by mismanagement of the umbilical cord, or, with more 
likelihood, to some endemic cause. From the umbilicus, the erysipelas 
extends to the integument of the abdomen, and frequently to the or- 
gans of generation. It sometimes gives rise to sphacelus of the in- 
tegument and subcutaneous cellular tissue, and terminates fatally. 

ERYSIPELAS PHLEGMOiSODES. 

Phlegmonous erysipelas is much more severe in its nature than the 
simple varieties, and affects the deeper-seated textures, the subcutane- 
ous cellular tissue, the superficial and deep fasciae, and the intermuscu- 
lar cellular "tissue, as well as the integument. It may occur on any 
part of the body, but is most frequently observed in the extremities. 
This form of erysipelas terminates rarely in resolution, commonly in 
extensive suppuration, and gangrene of the cellular tissue and fasciae. 

The constitutional symptoms are identical with those which accom- 
pany simple erysipelas, but more severe, the violence of the symptoms 
being in great measure dependent upon the extent and depth of the 
inflammation. When the disease spreads widely and deeply, there is 
delirium, a dry and brown tongue, frequently diarrhoea, and copious 
perspirations. 

The local symptoms, when the inflammation is comparatively super- 
ficial, are, vivid redness, which disappears on pressure, and returns 
slowly on its remission ; tumefaction ; a smooth, shining surface ; and 
an acute, burning pain, augmented by the slightest touch. On the 
fifth or sixth day, if active treatment have not been adopted, the pain 
diminishes and assumes a throbbing character, the redness subsides, 
and an obscure fluctuation may be felt over the surface. Suppuration 
has now taken place more or less extensively, and the pus burrows 
beneath the skin and fasciae in all directions, unless released by in- 
cision or ulceration. If an incision be made, it gives exit to healthy 
pus, mingled with small portions of dead cellular tissue. When the 
inflammation is disposed to terminate in resolution, the redness, pain, 
and swelling diminish on the fifth or sixth day, the epidermis becomes 
dry and scaly, and the effused fluids are gradually removed. 

If phlegmonous erysipelas attack more deeply-seated textures, or 
an entire member, the inflammation appears suddenly, the pain is 
more severe and distressing than in the preceding form, and the sur- 
face is vividly red, tense, shining, and exquisitely sensitive. On the 
fifth or sixth day, and sometimes earlier, suppuration takes place, 
accompanied by throbbing, and preceded by occasional chills and 
rigors. The redness and pain diminish on the occurrence of suppura- 
tion, and an obscure fluctuation and boggy sensation are felt on the 
application of the hand. If the parts be opened at this period by a 
free incision, a large quantity of pus will escape, mingled with con- 
siderable flakes of cellular tissue in a state of gangrene. Should the 
incision be neglected, the pus spreads around the limb, burrowing 
beneath the fasciae, between the muscles, and separating the integu- 



ERYTHEMATOUS OR EXANTHEM ATO US ERUPTIONS. 137 

merit from the parts beneath. Eventually, the matter discharges 
itself by means of ulceration ; but the constitutional irritation is ex- 
cessive ; hectic fever is induced, accompanied by colliquative diar- 
rhoea ; and the scene quickly closes in death. 

When the pus is bound down by aponeurosis, or fasciae, the consti- 
tutional effects are still more intense than those above described. 
The integument, in a few days, becomes livid and dark-colored, large 
vesicles or phlyctense, containing a purplish serum, rise upon the sur- 
face, gangrene ensues, attended with entire prostration of the physical 
powers, and death speedily follows. In some cases, however, when 
the strength of constitution of the patient enables him to resist the 
effects of sphacelus, sloughs are formed, which are thrown off, and a 
granulating surface is slowly established. The issue of phlegmonous 
erysipelas in mortification, constitutes the sub-variety, termed gan- 
grenous erysipelas [Erythema gangrenosum. Mason Good]. 

Diagnosis. — The principal diagnostic characters of erysipelas are, 
inflammation of the skin, extending more or less deeply into the sub- 
cutaneous cellular tissue ; tumefaction of the inflamed parts ; a special 
disposition to spread ; and symptoms of a dangerous fever, pursuing 
a regular and definite course. These signs serve to distinguish it from 
erythema, in which the inflammation is superficial, being limited to 
the derma ; there is scarcely any tumefaction of the inflamed parts ; 
the disposition to spread is comparatively absent ; and there is little 
constitutional disturbance. Erythema lseve may, at first sight, appear 
to be a contradiction to these characters, but the oedema in this affec- 
tion is the cause, and not the effect, as in erysipelas ; and erythema 
oedematosum may be regarded as a transition link between erythema 
and erysipelas. 

The uniform redness of the inflamed surface, and its partial seat, 
sufficiently distinguish erysipelas from other exanthematous fevers. 
A few instances are on record wherein erysipelas is stated to have been 
universal, but such cases must be extremely rare. 

Simple erysipelas is distinguished from erysipelas phlegmonodes, 
by the tumefaction of the latter extending more deeply, by the greater 
severity both of the local and constitutional symptoms, and by the 
violence of the inflammation expending itself on the part first attacked, 
without spreading to distant regions. 

Causes. — Erysipelas appears to originate sometimes in infection or 
contagion, and is now and then seen prevailing epidemically, or run- 
ning through the wards of an hospital. Puerperal fever has been 
shown to be one of the sources of the contagion of erysipelas, and the 
evidence on this head seems to place beyond question the fact, 
that these two diseases are reciprocally transmissible. 1 The predis- 
posing causes of erysipelas are, some inherent peculiarity of the con- 
stitution, as in cases where it occurs hereditarily ; or some morbid 
state of the system. It not unfrequently appears in those whose 

1 See an excellent paper on this subject in Dr. Ranking's "Abstract of the Medical 
Sciences" (vol. iv. 1846), from the pen of the editor. 



138 DISEASES ARISING FROM GENERAL CAUSES. 

nervous system is debilitated by mental emotions of a depressing 
kind, as anger and grief; by chronic disease ; or by excesses. Under 
these conditions, the most trifling irritation may give rise to the 
affections ; such as a scratch with a pin, a leech-bite, a blister, seton, or 
issue, &c. In like manner, a wound, either accidental, or occasioned 
by a surgical operation, may be the exciting cause of erysipelas. Per- 
sons with a thin and irritable skin, and members of the female sex, 
are especially liable to erysipelas. It makes its attack most frequently 
in the summer season, and is sometimes dependent on functional 
derangement, such as amenorrhoea, the critical period, &c. In delicate 
females it occasionally takes place periodically. 

Prognosis. — The prognosis of erysipelas depends upon the various 
circumstances enumerated amongst its causes. When the fever is 
moderate, the constitution sound, and the local inflammation not ex- 
tensive, the disease may be regarded as of little consequence. When, 
however, the constitution is debilitated, the invasion of erysipelas is 
to be apprehended, not only from the deficient power of the system, 
but also from the liability which exists to inflammation of the super- 
ficial veins and lymphatics, and purulent deposits in the viscera. The 
prognosis is also unfavorable when it occurs either in the very young 
or in the very old ; when it is associated with a wound ; when it is 
complicated with vomiting, or vomiting and purging ; or when it 
succeeds to anasarca. The metastatic form is always dangerous, from 
the possibility of some vital organ being secondarily attacked. Ery- 
sipelas erraticum occurring in the progress of chronic disease is also 
of dangerous import. Phlegmonous erysipelas, on account of its 
severity, is always dangerous, and requires the most vigilant care. 

Treatment. — The management of erysipelas presents two indica- 
tions : firstly, to subdue the fever ; and secondly, the local inflamma- 
tion. 

The first of these indications is to be effected by means of rest, an 
invalid diet, neither too low nor too stimulating, a brisk purge, aided 
by an active dose of sulphate of magnesia and senna, rhubarb and 
magnesia, or rhubarb and sulphate of soda, to clear out the digestive 
canal ; subsequently saline diaphoretics ; and if there be much irritabi- 
lity and restlessness, opium ; and when the violence of the febrile symp- 
toms has abated, or the vital powers flag, diffusive stimulants, wine 
and tonics. Few constitutions will bear the abstraction of blood ; and 
it must be remembered that erysipelas rapidly exhausts the powers of 
life, is asthenic in its character, and speedily makes a demand for 
stimulant remedies. An active purgative at the outset of the com- 
plaint, once or twice repeated, will, besides performing the necessary 
office of emptying the alimentary canal and biliary ducts, reduce the 
vascular system as much as the constitution will bear. We may then 
follow it up with the liquor ammoniae acetatis and sesquicarbonate of 
ammonia ; or the latter in effervescence with lemon-juice ; or, better 
still, the sesquicarbonate of ammonia should be given in simple solu- 
tion in water, in doses of three to six grains every two to four hours, 
as recommended by Drs. Peart and Wilkinson for scarlatina and 
measles ; and once or twice in a day a dose of Dover's powder. As 



ERYTHEMATOUS OR EXANTHEM ATO U S ERUPTIONS. 139 

soon as the first violence of the febrile symptoms is abated, the diet 
may be improved. Wine may be added, and tonics of bark or quinine 
with the mineral acids exhibited. 

The tincture of the sesquichloride of iron is regarded by Dr. George 
W. Balfour 1 as a specific. "Erysipelas," he observes, "is one of the 
few diseases for which I now believe we have a certain and unfailing 
remedy, and this, whether it be infantile or adult, idiopathic or trauma- 
tic." He first of all clears the bowels with a smart purge, such as ten 
grains of calomel with a drachm of jalap, or two drachms of sulphate 
of potash ; and then administers twenty drops of the tincture of the 
sesquichloride of iron in simple water every two hours until the dis- 
ease is subdued. He found it to remove pain, lessen the heart's action, 
clean the tongue, and to act as a diuretic on the kidneys ; while its 
special influence is exerted on the capillary vessels of the skin. It 
should be administered regularly, so as to saturate the system as 
quickly as possible ; for it is not until the point of saturation is attained 
that it effects its curative action. It may be given in any stage of the 
fever, even in high delirium ; it never produces headache ; it arrests 
suppuration even in phlegmonous erysipelas ; and it brings about a 
cure in less than a week. In infants of four months old he prescribes 
two minims as a dose, and increases the dose in proportion to the age 
of the patient. One of his cases brings the remedy in contrast with 
the sesquicarbonate of ammonia ; a patient affected with scarlatina was 
at the same time suffering under erysipelas ; the ammonia which he 
was taking for the scarlatina made no impression on the erysipelas ; 
but when the sesquichloride of iron was given the erysipelas got well. 

Dr. Robert Williams remarks with regard to the treatment of erysi- 
pelas : "The mode, then, in which I am in the habit of treating idio- 
pathic erysipelas, whatever may be the part affected, or with what- 
ever symptoms it may be accompanied, is as follows : The patient is 
put on a milk diet, the bowels gently opened, and from four to six 
ounces of port wine, together with sago, allowed daily. This mode of 
treatment it is seldom necessary to vary throughout the whole course 
of the disease ; for the delirium, if present, is generally tranquillized; 
if absent, prevented ; the tongue more rarely becomes brown, or only 
continues so for a few hours ; while the local disease seldom passes 
into suppuration or gangrene. In a word, all the symptoms are miti- 
gated, and the course of the disease shortened. I have pursued this 
system for several years, and I hardly remember a case in which it 
has not been successful." 2 

This author records several remarkable instances of the advantages 
of his method of treatment. He does not limit the quantity of wine 
to that above stated, but in more severe cases, when the local disease 
still continues to extend, and the delirium to augment, he increases the 
wine to eight ounces, and adds to it the influence of quinine. " Two 
cases of erysipelas," continues the author, "not less instructive, were 
recently treated in St. Thomas's. The patients were both stout, healthy 

1 Monthly Journal of Medical Science, vol. xvi, 1S53, p. 426. 
8 Page 284. 



140 DISEASES ARISING FROM GENERAL CAUSES. 

young women, and nearly of the same age ; the seat of the disease also 
was the same, on the head and face, and they suffered equally from 
delirium, so that the difference between them, if any, was scarcely dis- 
tinguishable. For the one, four ounces of wine were prescribed on 
the Saturday, and there appeared no sufficient reason to increase the 
quantity on the Monday : but between Monday and Thursday, the 
day on which I next saw her, she had so sank that it Avas impossible 
to recover her. The other case was admitted about three days later, 
and, in the first instance, only four ounces of wine were prescribed for 
her ; but, warned by the fate of the former person, although she was 
highly delirious, I immediately increased the wine to eight ounces, 
and added also two grains of quinine every six hours. Under this 
treatment she rapidly recovered, so much so, that in four or five days 
it was thought practicable to reduce the wine to its original quantity, 
or to four ounces. But on this reduction being made the disease 
immediately returned, and it was once more necessary to raise it to 
eight ounces, and the patient now rapidly recovered." 

Mr. Grantham of Crayford, in Kent, a successful practitioner and 
original thinker, suggests the propriety of making early observation 
of the state of the urine in erysipelas. "I begin," he observes, "with 
large doses of carbonate of ammonia, spirits of ammonia, and camphor 
mixture, as an alkaline mode of treatment, which is generally indicated 
in the early stage of the inflammation, but towards the sequel of the 
disease a contrary mode of treatment is necessary, namely, small doses 
of sulphate of magnesia, with full doses of the acidum sulphuricum 
aromaticum. The diet should be liquid and nutritive, with a full pro- 
portion of common salt; and narcotics should be avoided unless indi- 
cated by an alkaline state of the urine." It must be remembered 
that Mr. Grantham's field of observation is a healthful neighborhood, 
remote from the causes of depression which exist in towns and cities. 
In the latter sedatives appear to form as essential a part of the treat- 
ment as stimulants. The dose of sesqiiicarbonate of ammonia may be 
as much as five or six grains every three or four hours. 

By some practitioners an emetic has been strongly recommended in 
the outset of the fever, and followed up during its progress by small 
doses of tartarized antimony. The excitability which accompanies the 
fever is to be calmed by sedatives, such as hyoscyamus and morphia, 
as circumstances may suggest, the latter remedy being frequently 
necessary at night, and in the more advanced stages of the disease. 
Two valuable and important medicines in erysipelas are aconite and 
belladonna; both of these remedies act by reducing the excitement of 
the arterial system, and procuring rest. The extract of aconite is 
especially useful in checking the heart's action, and promoting cuta- 
neous transpiration, and for this purpose should be administered in 
half-grain doses every four hours. Mr. Liston remarks, that after the 
aconite has performed its office, the extract of belladonna, in doses of 
one-sixteenth of a grain, is productive of the most beneficial effects. 

In erysipelas about the head and face, the feet and legs of the patient 
should be immersed in a mustard bath, and mustard poultices or blis- 
ters applied to the calves of the legs. 



ERYTHEMATOUS OR EXANTHE M ATO U S ERUPTIONS. 141 

The second indication, namely, that which relates to local treatment, 
is to be fulfilled, in milder cases, by rest, position, evaporating lotions, 
sedative lotions, poppy fomentations, or water-dressings, the tempera- 
ture of the applications being determined by the feelings of the patient. 
A lotion which I have found of much service in allaying the uneasi- 
ness of feeling attendant on erysipelas, is one composed of a drachm of 
sesquicarbonate of ammonia, the same quantity of diacetate of lead, 
and half an ounce of laudanum to a pint of water. But inunction 
with lard is in every way superior to all fluid applications. My friend, 
Mr. Grantham, to whom I am indebted for the first suggestion of lard, 
remarks with regard to its use : " My plan is to relax the skin with 
hot water or steam fomentations, and, after each fomentation, to satu- 
rate the inflamed surface with hot lard, which is afterwards covered 
with wool." If there be soreness of throat from congestion of the 
fauces, it should be touched with nitrate of silver. 

On the head and face, fomentations and fluid applications are gene- 
rally inconvenient, and their place may be usefully supplied by in- 
unction with lard, or by flour dusted copiously on the surface from the 
dredging- box. In more severe cases the congestion of the vessels of 
the skin is best relieved by puncturing the surface very freely with 
the point of a lancet, and afterwards using warm sedative lotions and 
fomentations of chamomile and hops. 

This practice was pursued by Sir Richard Dobson for many years, 
and always with the most favorable results. He observes that the 
punctures heal in the course of a few hours, that he makes them on 
every part of the body, and that he never saw any ill consequences 
result. Sir Richard Dobson was in the habit of making from ten to 
fifty punctures, about a quarter of an inch in depth, on the inflamed 
surface, and repeating the operation two or three times a day, as the 
case appeared to demand. Mr. Liston advocates the same plan. For 
some time I have adopted this method in the local treatment -of erysipe- 
las, and always with good effect. It is remarkable how quickly the 
tension and pain are diminished, and the tumefaction reduced. 

The relief afforded to the inflamed surface by inunction and punc- 
ture, must be referred to two principles altogether different from each 
other; the one being, so to speak, endosmotic, the other exosmofcic. 
But a substance which has been recently employed as an application 
to the skin, namely, collodion, is known to possess both these proper- 
ties in conjunction, and, among the numerous experiments which have 
been made of its virtues, has been found to be a valuable topical agent 
in erysipelas, compressing the surface, and so relieving tension and 
pain, constituting an impermeable varnish, and so preventing cuta- 
neous oxygenization of the blood, and the development of caloric, 
which results from that chemical combination. As the purpose of the 
collodion is to form an impermeable covering, it should be applied with 
;i brush over the entire of the inflamed surface, and repeated as fre- 
quently as may be necessary. 

Great benefit is sometimes derived from the application of a strong 
solution of nitrate of silver to the inflamed surface. Mr. Higginbot- 
tom, of Nottingham, by whom this mode of treatment is recommended, 



142 DISEASES ARISING FROM GENERAL CAUSES. 

gives the following statement of his plan : " The part is first to be 
washed in soap and water, to remove any oily substance from the 
skin, and then is to be wiped dry ; the inflamed and surrounding skin 
is next to be moistened, and a long stick of the nitrate of silver is to 
be passed over the moistened surface, taking care that not only every 
part of the inflamed skin should be touched, but the surrounding 
healthy skin, to the extent of an inch or more beyond it, in severe 
cases. The nitrate of silver may then be passed over these surfaces 
once, twice, thrice, or more times, according to the degree of inflam- 
mation ; once in slight cases, twice or three times in common cases, 
and more frequently if quick vesication be required." During the last 
eleven or twelve years Mr. Higginbottom has found a solution of eight 
scruples of nitrate of silver with twelve drops of nitric acid in an ounce 
of water, more convenient than the solid salt. He regulates the appli- 
cation of the solution according to the degree of severity of the local 
inflammation, and prefers a dossil of lint, tied on the end of a piece of 
stick, to a camel' s-hair pencil, for its diffusion over the surface. " The 
success of the nitrate of silver in external inflammation depends upon 
its strength and its proper application. The method of applying it 
by some practitioners appears to me to be quite trifling with the 
remedy. Instead of covering the whole inflamed surface and the sur- 
rounding healthy skin with the nitrate of silver, so as to cover the 
whole of the inflammation, they simply apply it around the inflamed 
surface, a mode of proceeding which has seldom the power of even 
preventing the spreading of the disease, or the deeper mischief when 
the inflammation itself is unarrested. Sometimes, even after the most 
decided application of the nitrate of silver, the inflammation may 
spread, but it is then generally much feebler in character, and easily 
checked by the repeated application of the remedy." " I consider the 
application of the nitrate of silver as perfectly safe. I have seen no 
case of metastasis or any other bad effects from the use of it during 
upwards of twenty years." 1 Mr. Higginbottom further recommends 
that where erysipelas extends to the scalp, the head should be shaved, 
in order that the extent of the disease may be fully ascertained, and 
that the solution may have a fair chance of completely covering it. 
It should be applied very freely on the scalp, where, he informs me, 
"it scarcely ever produces vesication." 

M. Jobert 2 has used, with great success, an ointment composed of 
nitrate of silver and lard, in the proportion of from two to four drachms 
of the salt to an ounce. This is applied night and morning to the in- 
flamed skin, and for a small space beyond it, and a thin layer is left 
on the surface. 

The nitrate of silver is an excellent means of limiting the extension 
of the disease, by encircling the inflamed part with a line drawn with 
a wetted stick of the caustic. When an extremity is attacked, the 
defensive cordon must extend completely around the limb, above the 
affected part ; and if this simple manoeuvre be properly performed, 
the inflammation will, in many cases, be limited to the part first 

1 Lancet, vol. ii., 1S43, p. 515. * Gazette des Hopitaux, May 11, 1848. 



ERYTHEMATOUS OR EX ANTHEM ATOU S ERUPTIONS. 143 

attacked. Nitrate of silver appears to act by exciting an effusion of 
lymph and adhesive inflammation in the line of its application, which 
opposes an obstacle to the propagation of the exanthema ; upon the 
same principle, a narrow or linear blister has been used to form the 
circle, but whether it possesses any superiority over the nitrate of 
silver is very doubtful. The erratic form of erysipelas may frequently 
be fixed to the spot originally affected, by the application of a blister ; 
and this is the practice usually resorted. to for the purpose of recalling 
the disease, where it has suddenly disappeared by metastasis. In 
erysipelas phlyctenodes the vesicles should be opened, and the con- 
tained fluid gently pressed out and absorbed by a soft sponge. The 
epidermis of the phlyctense should be preserved as entire as possible, 
and replaced upon the denuded derma. This manner of treating the 
vesicles of erysipelas is infinitely superior to the ancient plan of 
covering them with starch powder, zinc powder, &c. (Edematous 
erysipelas is especially benefited by the punctures above recom- 
mended, followed, as soon as the inflammation is subdued, by com- 
pression with a bandage. Erysipelas of the scalp, when it affects the 
deep-seated textures, as in wounds and bruises of the head, is instantly 
relieved, and the danger of the disease mitigated, by a free incision 
carried down to the bone. 

Velpeau recommends a solution of sulphate of iron, in the pro- 
portion of an ounce to the pint of water, as a local application in 
erysipelas. This solution, he remarks, produces a sudden improve- 
ment in the patches, and causes their decline in one or two days. As 
frequently as new patches make their appearance, they are to be 
treated in the same manner, until the constitutional morbific influence 
is expended. In situations where a lotion would be inconvenient, 
this surgeon employs an ointment, containing a drachm of the salt to 
an ounce of lard. 

Dr. Fahnestock, of Pittsburg, speaks in great praise of pure creasote 
as a local application in erysipelas. It should be sufficiently strong 
to render the cuticle white immediately it is applied, and should be 
pencilled over the whole of the inflamed surface, and for a small space 
beyond it. In phlegmonous erysipelas the application should be made 
more frequently than in the idiopathic kind, and a cold bread poultice 
or compress, moistened with a solution of creasote, kept on the part. 
When the mucous membrane of the mouth or fauces is affected, he 
uses a solution of nitrate of silver, of the strength of half a drachm or 
a drachm to the ounce. 

Dr. James Arnott advocates congelation as a local remedy for ery- 
sipelas, and adduces numerous cases as examples of its success. 

Phlegmonous erysipelas requires great activity of. management. 
At the outset of the inflammatory attack the patient should be freely 
purged. The affected part should be placed in a position to facilitate the 
circulation through the limb as much as possible. Leeches should be 
applied, and followed by fomentations and water-dressings. If these 
means fail to restrain the progress of the disease, two or more 
incisions, according to the extent of the inflammation, should be 
made through the affected tissues, so as to divide freely the superficial 



144 DISEASES ARISING FROM GENERAL CAUSES. 

and deep fascia, and offer a clear passage to any pus that may have 
been formed. To effect the object completely, the incisions should be 
two or three inches in length, and sufficiently deep. The advantages 
of this mode of treatment are obvious; the congested vessels of the 
inflamed part are relieved, and the tendency to morbid action conse- 
quently diminished. The tension, pain, and tumefaction are reduced, 
even where no matter is already formed; and when suppuration is 
established, a free outlet is given to the pus, and flakes of gangrenous 
cellular tissue. Whenever we are led to infer, from the severity of 
the constitutional symptoms, that pus is bound down by fascia, as in 
the hand and foot, a free incision is the proper treatment, even 
although no swelling may be present. After the incisions, the 
fomentations and warm water-dressing should be continued ; and on 
the decline of the inflammation, a bandage applied, to facilitate ab- 
sorption of the fluids effused into the surrounding tissues. 

The general treatment applicable to erysipelas phlegmonodes is the 
same as for simple erysipelas, and sedatives are especially valuable. 
As soon, however, as the immediate inflammatory symptoms have sub- 
sided, tonics must be employed and aided by a more generous diet. 



ROSEOLA. 

Syn. Exanthesis roseola ; Mason Good. False measles. Rose-rash. 
Cutaneous blush. Moseole, Fran. 

Under the name of roseola, Willan has described certain forms of 
cutaneous inflammation, some of which seem to occupy a middle posi- 
tion between erythema, urticaria, and rubeola, without being strictly 
referable to either ; while others ought more properly to be considered 
under one or other of the before-mentioned heads. The title of this 
affection is, perhaps, the most objectionable in the entire nomenclature 
qf diseases of the skin, since color can only be an accidental character, 
depending for its existence upon a greater or less congestion or dis- 
tension of the vascular rete of the derma, and, therefore, liable to con- 
stant change from trivial causes. The true characters of the disorder 
must evidently be sought in the morbid conditions which collectively 
constitute the disease ; in other words, in those symptoms which ap- 
pear to be characteristic of the affection. 

Roseola (Plate VII.) is a non-infectious and non-contagious inflam- 
mation of the skin ; characterized by febrile symptoms which assume 
the subacute type, by patches of redness, of small size and irregular 
form, distributed over more or less of the surface of the body, and by 
more or less redness of the fauces. The exanthema is transient, is 
accompanied by more or less prickling or tingling of the skin, is 
brightly red or crimson at first, subsides gradually into a dull roseate 
tint, and disappears by degrees, often leaving behind it petechial or 
ecchymosed spots and the discoloration which follows a bruise. 

Willan has described seven varieties of roseola, to which five other 
varieties may be added ; three of these, namely, roseola rheumatica, 
arthritica, and cholerica, resting on the authority of Bateman and 



ERYTHEMATOUS OR EXANTHE M AT U S ERUPTIONS. 145 

Rayer ; one, roseola punctata, described by myself; and one, roseola 
febris continue, embracing the roseolous eruption common to typhus 
and typhoid fever. The whole of these forms may be arranged into 
two groups : idiopathic, in which the exciting cause is not immediately 
manifest; and symptomatic, which depend obviously upon some local 
source of irritation, or are associated with some existing disease. 
These are — 

Idiopathic. Symptomatic. 

Roseola infantilis, Roseola variolosa, 

" sestiva, " vaccina, 

" autumnalis, " miliaris, 

" annulata, " rheumatica, 

" punctata. " arthritica, 

" cholerica, 
" febris continuse. 

ROSEOLA INFANTILIS. 

False Measles. •, 

In roseola infantilis the patches of redness are of small size, and 
closely grouped together, and resemble, in general appearance, the 
eruption of rubeola. They are subject to much variety in relation to 
extent, duration, and the local inconvenience to which they give. rise. 
Thus, in one case, they are limited to a small district of the skin, or 
to the limbs, while in others they are dispersed over the entire body. 
In one case, again, they are fleeting, and disappear in the course of a 
day or two, while in others they are prolonged to a week or more. 
Sometimes they are productive of little inconvenience, and at others 
excite troublesome itching and tingling. The constitutional symp- 
toms, like the other characters of the affection, are marked by uncer- 
tainty in respect of degree ; in some subjects the febrile indications 
are severe and active, while in others they are transient, and speedily 
decline. 

ROSEOLA ESTIVA. 
• False Measles. 

Roseola sestiva (Plate VII., e.) is the common form under which the 
disease presents itself in the adult: it is developed, as implied by its 
name, chiefly in the summer season, and attacks persons of a weakly 
and irritable state of system, particularly of the female sex. The 
disorder usually commences with the ordinary series of febrile symp- 
toms of the slighter kind, namely, chills succeeded by flushes of heat, 
languor, pains in the head, back, and limbs, restlessness, quickened 
pulse, and thirst. These are followed, in a few days, varying in 
number from three to eight, by an eruption appearing first about the 
face, neck, and arms, and then extending to the body and lower ex- 
tremities. In general appearance the rash resembles rubeola; 1 but, 

1 " Portraits of Diseases of the Skin :" the eruption of Roseola is well shown in Plate 
XXIV., P., which represents a case of Roseola Syphilitica. 

10 



146 DISEASES ARISING FROM GENERAL CAUSES. 

on closer examination, is found to consist of patches of larger size 
and more irregular form, and, at a later period, the difference is still 
more striking, in consequence of the change of tint to a dark roseate 
hue. The fauces are also affected by the disease, presenting a deep 
red tint, with some degree of swelling of the mucous membrane, and 
enlargement of the tonsils. The eruption appears ordinarily in the 
evening, and arrives at its height on the following day, being 
accompanied with tingling and itching. On the fourth day the rash 
begins to fade, and on the fifth disappears, together with the constitu- 
tional symptoms. 

The eruption is sometimes local in its attack, being confined to the 
face and neck, which become tumefied, and exceedingly painful. It 
is liable also to delitescence, in which case the constitutional symptoms 
are aggravated, and relieved only by the reappearance of the rash. 

ROSEOLA AUTUMNALIS. 

Roseola autumnalis is met with chiefly among children, but I have 
seen it also in the adult, and it occurs generally during the autumnal 
season. The constitutional symptoms are very slight, being limited 
to a trifling indisposition, with congestion of the fauces. The eruption 
appears in roundish circumscribed patches, of about the size of a 
shilling, and of a very dark hue, seeming, at a distance, "as if stained 
by the juice of black cherries or mulberries." The patches occur 
most frequently on the arms and legs, rarely on the face and body. 
They continue for about a week, give rise to very little itching or 
local inconvenience, and are succeeded by a slight furfuraceous des- 
quamation. 

ROSEOLA ANNULATA. 

This form of roseola 1 is characterized by the figure of the eruption, 
appearing, in the first instance, as rose-red circular spots, and increas- 
ing in a short space of time into rings of variable size, having a central 
area of natural skin. This eruption possesses all the general charac- 
ters of roseola, as described in roseola sestiva. It appears after a 
slight attack of constitutional symptoms, which are relieved by the 
outbreak of the eruption, and aggravated if it should chance to 
recede; it occasions considerable tingling and smarting of the skin, 
which are increased during the night, so as frequently to destroy rest; 
and it affects, more or less extensively, the mucous membrane of the 
fauces. When the disorder sets in with severe symptoms, the eruption 
reaches Its height on the fourth day, and terminates, like roseola sestiva, 
at the end of a week or ten days. When, however, it assumes a 
milder type, it may endure for several months, and recur at intervals. 
Willan relates the case of a lady who suffered from this disease for 
several months together for three successive years. On its decline, it 
leaves behind it stains on the skin like those produced by a bruise ; 

1 " Portraits of Diseases of the Skin,'" Plate II., AK, exhibits a good example of Roseola 
Annulata. 



ERYTHEMATOUS OR EX ANTHEM A TO TJ S ERUPTIONS. 147 

and not unfrequently a deep-seated tenderness, as if the bruise ex- 
tended into the substance of the limb. 



ROSEOLA PUNCTATA. 

Roseola punctata is a rare affection, of which I have seen only a few 
examples. Its characters are as follow : 

Febrile symptoms of a subacute type, accompanied with redness of 
the eyes, slight coryza, redness of the fauces, and swelling of the 
mucous membrane of the mouth, ushering in an exanthema at the end 
of three days ; the exanthema appearing on the mucous membrane 
and skin ; on the latter, in the form of small red spots occupying 
the mouths of the follicles, then becoming diffused so as to cover 
the greater part of the body, reaching its height on the third day ; at 
first of a bright raspberry-red color, afterwards acquiring a dull rose- 
ate hue, the dulness increasing with the progress of decline ; the 
primary red spots resembling dull red stains as decline advances, and 
fading by degrees after the disappearance of the rash ; the entire 
attack lasting ten days, of which three belong to the febrile period, 
three to the exanthema, and four to its decline, the dark stains being 
perceptible for some clays afterwards, the rash assuming a difference 
of form on different parts of the surface, such differences being all 
referable to roseola. The following is an example of this form of 
exanthema. For the opportunity of observing it I am indebted to 
Mr. Marson, the resident surgeon of the Small-pox Hospital, who, 
during a connection of twelve years with that hospital, has seen about 
ten cases : 

A young man, aged twenty-four, of good constitution, engaged as 
light porter in a draper's house in Oxford Street, exposed himself to 
cold by riding on the outside of an omnibus during the prevalence of 
cold winds. At the end of his journey he felt chilled, and, in the 
course of the same evening, experienced headache, pain in his limbs, 
and sensations of general illness. 

Sept. 8th. — On the following morning, after a restless night, he arose 
fatigued ; his headache had increased, his appetite was gone, and he 
performed his duties painfully and wearily. He was chilly during the 
day, and in the evening feverish; had a dry mouth, and retired early 
to bed. 

9th. — He had still greater difficulty in getting through his work to- 
day than yesterday. His symptoms were the same, but increased in 
severity. At night, after getting to bed he smoked a cigar and took 
a basin of gruel, and being well covered up, broke out in a profuse 
perspiration. 

10th. — This day he scarcely felt able to rise from his bed ; but suc- 
ceeded in getting down stairs and cleaning some knives. While 
engaged in thai occupation he observed an eruption of small red spots 
on his arms, and soon afterwards returned to his bed. On taking off 
his clothes he found his whole body covered with spots, the upper 
parts being most, and the lower least affected. He remarked, also, that 



148 DISEASES ARISING FROM GENERAL CAUSES. 

his eyes looked red, that his lips were swollen, and that there were red 
spots likewise inside his mouth. 

11th. — Having been seen this day by a medical man, he was sent 
to the Small-pox Hospital, under the impression that the eruption was 
incipient small-pox. At this time the eruption consisted of small red 
spots, the centre of each spot being very slightly raised, and corres- 
ponding with the aperture of a cutaneous follicle. 

12th. — The redness of the eyes, accompanied with coryza in a slight 
degree, the swelling of the lips, and the spotted state of the mucous 
membrane of the mouth, were at their height to-day, and to these 
symptoms were superadded a cough, making the general symptoms 
very similar to those of rubeola. The red spots had now become con- 
fluent, and assumed the character of patches, which covered the greater 
part of the body. The congested skin was slightly raised above the 
level of the unaffected parts, and the color presented the raspberry 
hue of measles. 

13th. — The patient's eyes were still somewhat congested, his lips 
swollen and dry, the mucous membrane of the mouth was thickly 
covered with red spots, the fauces were red, his tongue was coated with 
a white, moist deposit, which was beginning to separate in flakes, 
leaving the surface beneath quite smooth, and he uttered occasionally 
a short, mucous cough. 

The efflorescence had a decidedly rubeolous hue, but offered some 
variety of appearance on different parts of the body. On his face, 
which was somewhat swollen, the patches of redness were irregular in 
form, and diffused. 

On the trunk of the body, and particularly on the abdomen, the 
efflorescence presented the ordinary rubeolous appearance of common 
roseola. 

On the arms and legs the red patches had run together, so as to 
cover the greater part of the skin, and form a dull, red ground, which 
was studded all over with spots of a dark red color. These spots, 
which I have assumed as the specific character of the eruption, were 
the original red points by which the efflorescence commenced. They 
presented a deeper red than the rest of the surface, Avere about two 
lines and a half in diameter, and were dark and slightly raised in the 
centre. The redness was partly the effect of congestion, and partly of 
transudation of the coloring principle of the blood ; and in some 
few situations, as around the ankles, and upon the back of the shoul- 
ders, where the weight of the body rested, there was a decided ecchy- 
mosis from the latter cause. It was obvious that these red points 
represented the follicles of the skin, in which the inflammation com- 
menced, and the elevated centre was the pore raised above its natural 
level. ;is a joint effect of the congestion of the capillary vessels, and 
effusion into the meshes of the vascular network. 

On the neck the efflorescence appeared in the form of patches dis- 
tinctly circumscribed, slightly elevated, more or less circular in figure, 
and of an average size of half an inch in diameter. On careful exami- 
nation, these patches were seen to be formed by the confluence of a 
number of small circular congested spots, each taking its rise around 



ERYTHEMATOUS OR EXANTHEM ATO U S ERUPTIONS. 149 

the aperture of a follicle, and many of these separate spots, of about a 
line in diameter, were sprinkled in the interspaces of the patches. In 
several of the larger patches there were one or more yellowish spots, 
which, at first sight, gave the idea of the elevations of urticaria, but 
which the changes succeeding on the following day proved to be faded 
points indicating the decline of congestion. The increase of these 
pale spots gradually converted the patches into rings, and the latter 
finally disappeared. I must remark, that the spots above referred to 
were quite distinct from the deeper colored and star-like spots on the 
arms, which suggested the specific name, "punctata," which I have 
given to the disease. 

14th. — The eruption is now on the decline. The efflorescence is of 
a duller hue ; the spots have more the character of stains than yester- 
day, and the patches on the neck are converted into rings ; on the 
abdomen, chest, and thighs, the efflorescence is fading away, like ordi- 
nary roseola. 'The thin skin of the penis has a remarkable appear- 
ance, from being covered with deep rose-red stains. 

On Friday, and the two following days, the general symptoms im- 
proved, while the efflorescence continued to fade, and on Monday he 
was sufficiently well to be revaccinated, and to leave the hospital. 

ROSEOLA VARIOLOSA. 

Variolous roseola is an erythematous inflammation of the skin, 
which not unfrequently attends the eruptive fever of inoculated small- 
pox, appearing on the second day from the commencement of the con- 
stitutional symptoms, and the ninth or tenth after inoculation. It 
shows itself, in the first instance, on the breast, the face, and arms, 
and then extends, during the second day of its eruption, to the trunk 
and lower extremities ; on the third day the roseate rash diminishes 
in vividness, and on the fourth subsides altogether. The proportion 
in which roseola occurs in inoculated small-pox is one in every fifteen 
cases. In natural small-pox it is more rare. 

Variolous roseola has been regarded as favorable to the prognosis 
of small-pox, and indicative of a mild eruption. When, however, the 
color of the rash is deep and dusky in its tint, and the eruptive fever 
severe, the most dangerous form of small-pox may be apprehended. 
In some instances of inoculation, the roseola has been known to super- 
sede the eruption of the small-pox, and the patient is said to be equally 
protected against variolous infection. It occurs chiefly in persons 
endowed with a delicate and irritable skin. 

In the management of cases of this affection, it is desirable to guard 
against the retrocession of the rash. For this purpose, the patient 
should be confined to his room, although children so affected are 
frequently carried into-the air, and exposed to the cold, without incon- 
venient results. 

ROSEOLA VACCINA. 

Roseola vaccina is an efflorescence similar to that which accom- 
panies variola ; it follows the development of the vaccine vesicle, 



150 DISEASES ARISING FROM GENERAL CAUSES. 

appearing on the ninth or tenth day, but much more rarely than after 
inoculation. It occurs in the form of small erythematous patches, 
which seem to be propagated from the inflamed halo of the vaccine 
reside, and, in Borne instances, are diffused over the entire surface of 
the body. The eruption rarely lasts more than two days, and appears 
only in children possessed of a delicate and irritable skin. 

ROSEOLA MILIARIS. 

Under the name of roseola miliaris, Bateman* describes an erythe- 
matous inflammation of the skin, accompanied by the development 
of small vesicles, which he observed on the ninth day and towards the 
close of continued fever. This eruption consisted of oval-shaped and 
slightly-raised patches, which appeared upon the arms and breast, and 
were followed by a decided remission of the febrile symptoms. The 
patches increased in size for the space of three days ; they were of a 
bright rose color at first, diminishing gradually in redness, and 
assuming a bluish tint, and at the end of this period they disappeared 
altogether. 

Miliary vesicles, or sudamina, are not unfrequently met with during 
the second week of typhus, typhoid, and relapsing fever ; they are 
most commonly developed on the sides of the neck, on the chest, and 
in the axillse, and are usually associated with the roseola of those 
fevers ; they generally accompany the perspirations which occur 
towards the end of the second week of typhus and typhoid fever, and 
the critical sweat of relapsing fever. Appearing under these circum- 
stances, their consideration belongs to continued fever rather than to 
roseolous eruption. 

ROSEOLA RHEUMATICA ET ARTHRITICA. 

Rheumatic and arthritic roseola is an erythematous inflammation 
of the skin, appearing in spots and patches, of various size and form, 
and upon different parts of the body, in persons affected with rheu- 
matism or gout. In some instances the efflorescence precedes the 
attack, which invades immediately upon its decline ; in other cases, 
the eruption appears during the progress or towards the close of the 
disease. In Wurzburg, where rheumatism is endemic and very severe, 
the exanthem makes its attack at the commencement of the disease, 
and after one or two days of suffering from gastric and febrile affec- 
tion. The eruption in this case consists of small roundish spots, which 
first show themselves on the legs, and thence extend to the rest of the 
body. They present the deep rosy color, subsequently becoming 
purplish and livid, which is characteristic of roseola. 

ROSEOLA CHOLERICA. 

This form of roseola rests on the observation of Rayer, who saw the 
variety dining the prevalence of cholera, in Paris, in 1832. "After 
the period of reaction," he says, "there occurred in some patients, 



ERYTHEMATOUS OR EX ANTH E M AT U S ERUPTIONS. 151 

especially in women, an eruption which most generally appeared on 
the hands and arms, and then extended to the neck, the breast, the 
belly, and the upper and lower extremities. At its commencement it 
was characterized by patches, for the most part of an irregularly 
circular shape, of a bright red color, elevated above the surface, and 
but slightly itchy. Very numerous on the hands, arms, and chest, 
they were less so on various other parts ; in some places they were 
crowded together, tended to confluence, and had an appearance very 
analogous to the efflorescence of slight scarlet fever ; in other places 
the aspect of the eruption was rather like that of measles; and in 
others even more like that of urticaria. 

"I have seen this inflammation complicated with an inflammatory 
affection of the fauces and tonsils, and its disappearance followed by 
an aggravation of the general symptoms, and, sometimes, even by 
death. On the chest the spots occasionally became confluent, and gave 
rise to patches as broad as the hand, raised above the general level, 
and pretty well defined. The eruption then acquired a dirty pink or 
rose color. About the sixth or seventh day the epidermis cracked, 
and was thrown off in large flakes on almost all the places where the 
eruption had existed." 

ROSEOLA FEBRIS CONTINUE. 

Roseola is not unfrequently present in continued fever, in typhus, 
in typhoid fever, and in the relapsing fever; and may be regarded as 
the cutaneous manifestation of the elimination of the special poison of 
continued fever from the blood. In these fevers the skin is more or 
less muddy and discolored, and at the beginning of the second week a 
roseolous eruption is developed more or less extensively over the 
surface, the characters of the eruption being influenced by the nature 
of the fever ; having a bright rose color in typhoid fever, and a mul- 
berry color in typhus. The exanthem may be distributed more or 
less profusely over the trunk of the body and limbs, or it may be 
limited to the extremities, and sometimes to the back of the hands; it 
rarely occurs on the face. The eruption is successive, a fresh crop 
taking place each day, and running a course of three days; so that 
after a few days it may be seen in all its stages, crescent, mature, and 
fading. 

The roseola of typhus is distinguished by its mulberry color and by 
its petechial character. It is persistent under pressure with the finger, 
and persistent after death. 

The roseola of typhoid fever is of a bright rose tint, often papular, 
scantily distributed over the surface, and disappears under pressure 
with the finger and after death. 

The roseola of relapsing fever passes quickly into the state of 
petechias, and is more frequently accompanied with miliary vesicles 
than the preceding form. 

Diagnosis. — Roseola is distinguished from other exanthemata by 
negative rather than by positive characters. The diseases with which 



152 DISEASES ARISING FROM GENERAL CAUSES. 

it is most likely to be confounded are rubeola, scarlatina, erythema, 
urticaria, and purpura. 

The varieties of roseola the most nearly allied in appearance to 
rubeola are, roseola infantilis and roseola sestiva ; but particularly the 
former, which is probably frequently mistaken for measles, and, 
indeed, is known by the trivial name of "false measles." The diag- 
nostic characters by which it is distinguished from rubeola are, the 
absence or extreme mildness of the catarrhal symptoms, the inferior 
degree of febrile affection, the larger size, more irregular form, and 
deeper color of the patches, their progress from the extremities to the 
trunk of the body, and above all, the uniformity of the redness as 
contrasted with the punctiform character of that of rubeola. More- 
over, the latter is contagious, and generally of epidemic origin, which 
is not the case with roseola. These remarks apply also to the diag- 
nosis between roseola and scarlatina, substituting for the catarrhal 
symptoms of rubeola the angina of scarlatina. 

The degree of congestion affecting the skin in roseola is very similar 
to that of erythema; in both the patches are irregular and uniform in 
tint, but in the former are for the most part smaller than in the latter, 
and of a venous character. The form originating in local irritation 
it would be more correct to consider as an erythema. 

From urticaria, the distinction of roseola lies in the light-colored 
and raised spots and wheals of the former, as contrasted with the more 
uniform redness of the patches of the latter. Sometimes, as in rose- 
ola annulata, the red spots have pale centres even at the beginning, 
but there is no elevation as in urticaria. The local inconvenience, 
also, is greater in urticaria ; for, although in both, itching and tingling 
are prevailing characters, these symptoms are more severe in urticaria, 
and are accompanied by pricking and stinging. 

Causes. — Roseola is met with in children, in persons with a thin 
and delicate skin, of weakly and irritable constitution, and particularly 
in females. In infants, the exciting cause is teething, intestinal irri- 
tation, or objectionable diet. In adults,- it may be occasioned by any 
causes which disturb the functions and circulation of the skin during 
its period of increased activity, namely, in the summer season. Of 
this kind are, exposure to a draught of cold air, Avhen the body is 
heated by exercise ; drinking cold water while the body is warm, 
distressing the stomach with an overload of fruit, indigestible sub- 
Btances, copaiba, &c. Other causes are, gastric and intestinal irrita- 
tion, and disordered menstruation. The forms called into action by 
local irritation are obvious in their causes, while those which accom- 
pany rheumatism, gout, cholera, or continued fever, are occasioned by 
an effort of evolution of the gouty or other morbid salts or poison by 
the skin. 

PROGNOSIS. — Roseola is a slight affection, and one of favorable ter- 
mination. When it occurs critically in connection with constitutional 
disease, it is of good omen, as implying a derivative action, and should 
he encouraged. 

Treatment. — In the treatment of roseola, the cause, when obvious, 
should be removed ; in the case of children suffering from dentition, 



ERYTHEMATOUS OR EX ANTH EM ATO US ERUPTIONS. 153 

this is best effected by scarifying the gums, and exhibiting a dose of 
castor-oil ; and where intestinal irritation is in fault, by one grain of 
calomel well triturated with one of sugar, by the hydrargyrum cum 
creta combined with rhubarb, by soda with rhubarb, or by fluid mag- 
nesia, to regulate the secretions, these measures being assisted by a 
light and moderate diet. In adults ; laxatives, diluents, and salines, 
followed, in weakly persons, by tonics combined with mineral acids, 
are the appropriate remedies ; a mixture consisting of infusion of roses, 
with one drachm of sulphate of magnesia, and one grain of sulphate 
of quinine the dose, will often conduct a patient to a favorable issue 
without any other assistance. The varieties accompanying particular 
diseases call for the treatment applicable to those diseases ; as, for 
instance, alkalies in the case of rheumatism, &c. When disordered 
menstrual function is the exciting cause, recourse must be had to steel 
medicines, aloetic aperients, &c. Local remedies are rarely necessary, 
and are only called for when the itching and tingling are troublesome. 
In this case, a lotion of sesquicarbonate of ammonia, a drachm to the 
half pint of rose-water ; a lotion of liquor ammonias acetatis with mis- 
tura camphorse, equal parts, and used tepid, or an emulsion of bitter 
almonds with hydrocyanic acid, a drachm to the half pint, and also 
used tepid, might be of service. Sponging with tepid water containing 
a little vinegar frequently answers every purpose. These remedies 
would only be required if the pruritus were severe, seeing that it 
would be undesirable to run the risk of chilling the surface and repel- 
ling the eruption. There is less chance of such an occurrence when 
an unguent is employed ; therefore, where a local application seems 
indispensable, the oxide of zinc ointment, rubbed down with campho- 
rated spirit or spirit of wine (5j ad §j) would be found to be the most 
efficacious ; or, simply, warm lard. 

URTICARIA. . 

Syn. Enantltesis urticaria ; Mason Good. Uredo. Nettle-rash. Fievre 
ortiee porcelaine. JSssera, Ital. Urticaire, Fran. Brennesse- 
lausschlag, Germ. Cnidosis, Alibert. 

Urticaria, or nettle-rash (Plate VII.), is a transient and non-conta- 
gious inflammation of the skin ; it is characterized by the eruption of 
small elevations, having a round, oval, or wheal-like form, of a whiter 
or redder tint than the healthy integument, and surrounded by a 
diffused redness of greater or less intensity. Urticaria is preceded and 
accompanied by febrile symptoms, and is associated with more or less 
irritation of the gastro-pulmonary mucous membrane. The eruption 
is Attended with itching, and a burning and tingling sensation like 
that produced by the sting of a nettle, and is occasionally followed by 
slight desquamation of the epidermis. 

The varieties of urticaria, distinguished by Willan, arc six in num- 
ber, of which two are referable to the acute, and four to the chronic 
form of inflammation. The six varieties are, 



154 DISEASES ARISING FROM GENERAL CAUSES. 

Acute. Chronic. 

Urticaria febrilis, Urticaria evanida, 

" conferta. " perstans, 

" subcutanea, 
" tuberosa. 

URTICARIA FEBRILIS. 

Febrile nettle-rash is especiclly characterized by the presence of 
severe constitutional disorder. It commences with a sense of weight 
and sickness at the stomach, white furred tongue, quick feverish pulse, 
pain in the head, anxiety, lassitude, faintness, and drowsiness. On 
the second day from the invasion of these symptoms, the patient is 
seized with rigors, which are followed by the eruption upon the skin 
of irregular patches, of a vivid red color, slightly raised above the 
level of the surrounding surface, and studded with whitish or reddish 
elevations and wheals. The patches are dispersed in various situations 
upon the surface of the body ; they appear and disappear unexpectedly, 
and without order, and may be produced instantly on parts apparently 
unaffected, by simply rubbing or scratching the skin. They are irre- 
gular in size and form, pale and little developed during the day, but 
brightly red towards the evening and during the night, at which time 
the febrile symptoms exacerbate, and the itching and tingling become 
more intense and troublesome. 

On the outbreak of the eruption, the pain and sickness at stomach 
are immediately relieved, but they are disposed to recur at each tem- 
porary disappearance of the rash. The disease usually runs its course 
in about a week ; at the end of that period the febrile symptoms and 
the eruption decline ; the bright and vivid red of the patches subsides 
into a pale and yellowish purple, and speedily disappears, leaving behind 
it a slight mealy desquamation of the epidermis, and sometimes oedema 
of the subcutaneous cellular tissue. 

Although febrile urticaria may be regarded as a mild form of cuta- 
neous exanthema, yet it is always troublesome and distressing to the 
patient, from the irritation with which it is accompanied. Frequently 
it creates alarm by the anxiety about the precordia and the syncope 
which attend its invasion ; and instances are not wanting in which it 
has proved fatal. "I saw it terminate fatally," says Willan, "in the 
case of a man about fifty years of age, who had impaired his constitu- 
tion by hard labor and intemperance. On the first and second day of 
August, 1792, he complained of nausea, and of great pain in the 
Stomach, which was increased on pressure. He was very thirsty, had 
a quick pulse, and a slight delirium at night. On the third and fourth 
days of August, a number of elevated wheals and red patches were dif- 
fused over the body, with much heat and itching of the skin. While 
the rash continued vivid his internal complaints abated, but on its 
sudden disappearance, about the fifth day, the febrile symptoms and 
delirium became more violent than at first. On the sixth day the 
eruption appeared again on his face; he was, notwithstanding, very 
hot, restless, and delirious ; he remained in' the same state during the 
following. day, and died in the evening." The same author also relates 



ERYTHEMATOUS OR EX ANTHEM AT U S ERUPTIONS. 155 

a very distressing case of this malady which occurred in a gentle- 
woman, twenty-seven years of age, and returned at intervals of a week 
for a considerable length of time. 

Febrile urticaria frequently attacks children, particularly during 
teething, and in them is remarkable for its unexpected development. 
Dr. Underwood observes that it "occurs in children more generally 
under two years of age, and is exceedingly troublesome to the infant, 
as well as matter of surprise to parents, from the suddenness of its 
appearance. Children going to bed perfectly well, wake very uneasy, 
and frequently continue screaming for some time before the cause is 
discovered. But upon examining the body and lower limbs, they are 
found covered with large wheals, similar to those produced by the 
sting of nettles." This description corresponds with that of an erup- 
tion, afterwards to be described, lichen urticatus, which is peculiar to 
children. 

Urticaria ah ingestis. — The symptoms produced by noxious alimen- 
tary substances are very remarkable and severe ; and in some instances 
have proved fatal, particularly when shell-fish have been the cause. 
The attack comes on suddenly, as, for instance, in the middle of the 
night, after a hearty supper, or a few hours after the exciting meal. 
The patient suffers from weight and an uneasy feeling in the stomach, 
accompanied with nausea and giddiness, and sometimes by vomiting 
and diarrhoea, a prickling sensation in the throat, and constriction of 
the fauces, which produces a short, troublesome cough, and occasion- 
ally threatens suffocation ; the tongue is swollen, and the voice altered 
from the extension of the swelling of the mucous membrane into the 
larynx. The face shortly begins to swell, while the ears, nose, and 
lips are burning hot, and itch violently. By degrees the eruption 
spreads to the trunk of the body, and from the latter to the limbs, 
affecting the joints particularly. When the rash reaches the extremi- 
ties the disagreeable symptoms pass off, and the patient recovers. This 
kind of attack generally terminates at the end of two days, and some- 
times after a few hours, leaving behind it little or no trace of its 
existence. 

URTICARIA CONFERTA. 

Urticaria conferta (Plate VII., e) is merely a severe degree of the 
local affection of urticaria. The elevation of the circular prominences 
and wheals is not so great as in the preceding variety, but they are 
more numerous, frequently coalesce, and are attended with considera- 
ble inflammation of the surrounding skin. The itching and tingling 
are exceedingly severe, particularly at night, and the integument is 
tumid and swollen. This form of the affection is apt to continue for 
several weeks. 

URTICARIA EVANIDA. 

Urticaria evanida (Plate VII., A a) is a chronic variety of nettle-rash, 
appearing and disappearing upon the skin in the form of white round- 
ish prominences and wheals, without febrile symptoms, and with trifling 



156 DISEASES ARISING FROM GENERAL CAUSES. 

redness. The eruption is not the less attended with troublesome itch- 
ing and tingling, particularly on the removal of the dress at bedtime, 
and on the return of warmth, induced by bed-clothes. It is chiefly 
remarkable for its duration, lasting sometimes for months, and even 
for years. 

URTICARIA PERSIANS. 

Urticaria perstans 1 differs from the preceding only in the persistent 
character of the eruption, which does net disappear, as in urticaria 
evanida, but continues unchanged for two or three weeks. It occurs 
chiefly on the limbs, and not so frequently on the trunk of the body. 
The gastric disorder, with the itching and tingling under the influence 
of heat, which are typical of urticaria, are also present in the per- 
sistent variety. 

URTICARIA SUBCUTANEA. 

Under the above title "Willan has described a nervous affection of 
the limbs, accompanied at intervals with an eruption of urticaria. 
"The eruption," writes Willan, "occurs at distant periods, and con- 
tinues only a few days at each return, but the patient is harassed dur- 
ing the intervals, as well as during the eruptions, with a violent and 
almost constant tingling in the skin, and with other distressing symp- 
toms. The complaint is at first confined to one spot on the leg or arm, 
and commences there ;with a sensation of tingling or stinging, which 
is afterwards felt more and more extensively along the limbs, or 
perhaps over nearly the whole surface of the body. Sudden changes 
of the temperature of the air, and agitation of mind, occasion increased 
uneasiness in the skin, so that pains are sometimes felt as from a sharp 
instrument puncturing in different directions; at other times, as from 
needles piercing or pushing the skin upwards. There is usually a 
stiffness and slight torpor in the muscles of the parts most affected ; 
an appearance of wheals takes place on the arms, chest, or lower ex- 
tremities, from time to time, especially during the summer. In most 
of the cases that I have seen or known the complaint was partial, 
affecting only the loins and thighs, or sometimes the arms." In illus- 
tration of this disease, Willan records the case of a lady, which 
appears rather to resemble a chronic affection of the spinal cord, 
attended occasionally with the eruption of urticaria. Stinging and 
pricking in the integument is a common symptom in diseases of the 
nervous system, but this surely affords no grounds for the designation 
subcutanea, as applied to this variety. 

URTICARIA TUBEROSA. 

Urticaria tuberosa appears chiefly in debilitated constitutions, and 
is a rare form of cutaneous disease. It has received its name from 
being characterized by the production of elevations of considerable 
size, and extending deeply into the subcutaneous cellular tissue. 

1 Portraits of Diseases of the Skin, Plate I., L. 



ERYTHEMATOUS OR EXANTHEMATOUS ERUPTIONS. 157 

These tumors are developed with much itching, during the night, 
upon the arms and legs ; they are painful and hot, and disappear 
before the morning, "leaving the patient weak, languid, and sore, as 
if he had been bruised, or had undergone much fatigue." The 
disease " often proves tedious and obstinate ; I have known it con- 
tinue," says Willan, " upwards of two years, with a few short intervals. 
The only causes to which it could, with probability, be attributed in 
the instances presented to me were, irregularities in diet, violent 
exercise taken by persons usually sedentary, and the too free use of 
spirituous liquors." 

Dr. Day, in his translation of Simon s Animal Chemistry, observes : 
" The urine in a case of urticaria tuberosa, has been analyzed by 
Scherer. The patient was a young man, who likewise suffered from 
rheumatism. The urine was discharged in very small quantity, often 
not more than five or six ounces in forty-eight hours. It was clear, 
of a brownish-red color, very acid, and its specific gravity was 1028. 
It contained in 1000 parts — 

Water, . . 931.58 

Solid residue, ........ 68.42 

Urea, 30.46 

Uric acid, 0.74 

Alcohol extract, with much lactic acid, . . . 21.24 

Water extract, 4.92 

Alkaline salts, 8.03 

Earthy phosphates, 2.02 

The most remarkable points in the constitution of the urine are the 
large amount of earthy phosphates, and the excess of free acid." 

In a case of urticaria, in which the urine was analyzed by Dr. 
Maclagan, its composition was found to be as follows : 

Urea, 6.91 

Uric acid, . 0.05 

Inorganic salts, ........ 12.03 

Organic matters and water, . . . . .981.01 

" The chief peculiarity in the present case was a deficiency in the 
ordinary characteristic ingredients of the urine, the urea and uric acid. 
This could not arise from mere excess of water : first, because the 
urine was not excessive in quantity ; second, because the inorganic 
salts were above the normal standard, whereas, had the water merely 
been in excess, they, too, ought to have indicated a diluted condition 
of the urine. Dr. Maclagan ventured, therefore, to propose, as the patho- 
logical view of the case, that the defect here was merely a deficiency 
of the urea and uric acid ; in short, a want of what modern chemists 
call the products of transformation of the tissues, and that the reten- 
tion in this way in the system of matters which ought to be eliminated 
from it might be the cause of this cutaneous irritation, especially 
occurring, as it did, after meals." 1 

With the view of modifying the imperfect transformation of tissues 
here referred to, the patient was treated with colchicum, upon which 

• Edinburgh Monthly Journal. 



158 DISEASES ARISING FROM GENERAL CAUSES. 

the specific gravity of the urine was found to have risen to 1029.9, 
and its composition to be as follows : 

Urea, 20.36 

Uric acid, 0.50 

Inorganic salts, ........ 12.72 

Organic matter and water, ...... 966.42 

The conclusions deduced from this observation are : 

1. u That urticaria is intimately connected with a deficiency of the 
organic salts of the urine, and their probable retention in the system. 

2. " That colchicum has an action capable of restoring the deficient 
salts, and thus curing the disease. 

3. " Rheumatism and urticaria, and purpura and urticaria, are fre- 
quently found to be present together. They are also benefited by 
the use of colchicum. It may be safely asked, do they not depend 
on the same common cause, namely, the presence of those salts in 
the blood? Such an inference has been applied in the case of 
rheumatism." 1 

Diagnosis. — The diagnostic characters of urticaria are, firstly, the 
appearance of the eruption, which resembles the whitish elevated 
spots and wheals produced by nettles; secondly, the itching, tingling, 
and pricking, which accompany the eruption ; thirdly, the evanescent 
and fleeting habits of the eruption; and fourthly, its association with 
symptoms of gastric irritation. These characters, well appreciated, 
sufficiently distinguish it from every other cutaneous eruption. 

The only affections to which urticaria bears so close a resemblance 
as to deserve remark, are, lichen urticatus, and erythema papulatum, 
tuberosum, and nodosum. The pimples of lichen urticatus are, how- 
ever, smaller and more persistent than the wheals of urticaria; they 
appear in successive crops, and become surmounted by a small 
dark-colored scab. Erythema papulatum resembles urticaria, both in 
general and local symptoms, but differs in its course and persistency. 
The spots of erythema tuberosum are quite superficial and persistent, 
as are those of erythema nodosum; characters which distinguish 
these eruptions from that of the transient and quickly fading urticaria 
tuberosa. 

Urticaria is occasionally complicated by the presence of other 
diseases of the skin, as erythema, roseola, lichen, and impetigo. It 
has also been observed with rubeola, variola, and prurigo. 

Causi s. — The proximate cause of urticaria is an irritation of the 
nerves of the skin, giving rise to the peculiar prickling and tingling 
sensation, and exciting spasm of the muscular structure of the 
coriom ; hence the white buttons and wheals emptied of their blood 
by muscular contraction, and developed on a surface reddened by 
vascular congestion; hence, also, the gradual subsidence of the 
wheals, the recovery of the natural tint of the skin, and their sud- 
den reproduction on the recurrence of slight irritation. In the 
instance of the rash occasioned by the sting of a nettle, the poisonous 
juices of the plant act directly on the nerves of the skin. In the 

1 Lancet, vol. ii. 1846, p. 160. 



ERYTHEMATOUS OR EX ANTHEM AT U S ERUPTIONS. 159 

case of urticaria excited by poisonous food, the action is an excito- 
sensory reflex operation, the seat of primary irritation being the 
nerves of the stomach ; while in other examples of the disease the 
primary irritation may exist in any organ supplied with sympathetic 
nerves ; in a word, urticaria is a neuropathic aifection, as distin- 
guished from erythema and roseola, which are hsemopathic disorders. 
This view of the pathology of urticaria explains its association with 
other eruptions of hsemopathic origin ; indeed, it is matter for sur- 
prise, that a spasmodic state of the muscular structure of the skin so 
rarely accompanies its inflammation in other diseases. 

The exciting causes of urticaria are referable to irritation of the 
gastro-pulmonary and genito-urinary mucous membranes. Thus it is 
induced by dentition, by gastric irritation, by intestinal irritation, by 
uterine irritation, and, more rarely, by pulmonary irritation. Mental 
excitement or anxiety, fatigue, exposure to cold or heat, also contribute 
towards its development, and occasionally it is seen in association 
with rheumatism. Among the causes of urticaria, nervous debility, 
occasioning a peculiar susceptibility of the cutaneous nerves, must 
not be omitted. In a lady who was lately under my care, I have 
watched the red wheals appear and creep along the skin and disap- 
pear, while I purposely engaged her in conversation on indifferent 
subjects. A word, .a look, the slightest excitement, would imme- 
diately bring out a copious eruption. It occurs chiefly in the summer 
season, and is said to be more prevalent in cold climates, as that of 
Russia, than in those of the south. Persons who possess a thin and 
irritable skin, who are plethoric and of a sanguine temperament, are 
most liable to the disease, and for this reason it is more common in 
the female than in the male sex. It is frequent in children, particu- 
larly during the period of dentition. 

The alimentary substances which are capable of exciting urticaria, 
act upon the system by means of the irritation which they cause to 
the mucous membrane of the alimentary canal. In some instances 
this irritation, is referable to the natural susceptibility of the indi- 
vidual ; while in others, the probable cause is a poison generated by 
putrefactive decomposition. The substances which have been ob- 
served to give rise to these effects in different persons are very 
numerous ; they are — some kinds of fish, as mussels, lobsters, crabs, 
prawns, shrimps, oysters, dried fish, &c. ; certain meats, such as pork, 
goose, &c. ; certain fruits and vegetables, as rice, almonds, strawberries, 
raspberries, cucumbers, mushrooms, &c. Rnyer mentions oatmeal 
gruel, as occasionally producing this effect ; and certain medicines, as 
valerian, copaiba, &c. A member of my own family suffers, con- 
stantly, after taking rice milk. Dr. Gregory was affected by the 
disease after eating part of a cucumber ; and he mentions two 
instances, of persons attacked in a similar manner from drinking 
porter. Dr. Winterbottom was " twice violently affected, by eating 
the sweet almond." Urticaria has been observed occasionally as a 
critical eruption, and has been stated by some authors to have 
occurred epidemically. 



160 DISEASES ARISING FROM GENERAL CAUSES. 

Persons of great cutaneous susceptibility have the power of exciting 
the eruption at any time, by merely scratching the skin. 

Prognosis. — Urticaria is not, in itself, a dangerous disease. The 
acute form is easily removed by appropriate treatment. Chronic 
urticaria is frequently symptomatic of nervous debility, mucous irri- 
tation, or visceral disorder, and may consequently prove obstinate, 
resisting all therapeutic measures until the disease of which it is a 
dependence is relieved. Retrocession of this eruption has sometimes 
been followed by a serious aggravation of internal disease.* 

Treatmknt. — The treatment of febrile urticaria should be strictly 
antiphlogistic ; in some cases it may be advisable to deplete by gene- 
ral bleeding ; in others, abstraction of blood from the neighborhood 
of the organs especially affected, by means of leeches, may suffice. The 
rest of the treatment should consist in the administration of aperients, 
salines, maintaining an abstemious and cooling diet, using the tepid 
bath and foot-bath occasionally, and if the seat of the visceral disorder 
be apparent, applying a blister over the organ affected. During 
convalescence, if the powers of the system have been reduced, tonic 
medicines, combined with alkalies or acids, according to the stage of 
the affection, should be prescribed. 

Where difficult dentition is the cause of eruption, the gums must be 
laid freely open with the lancet ; the little patient should be immersed 
once or twice daily in a warm bath, and some gentle antacid aperient 
administered. 

When the cause of the eruption is the ingestion of noxious and 
indigestible substances, no time should be lost in obtaining the ejec- 
tion of the offending matters. For this purpose the sulphate of 
zinc or sulphate of copper is best suited; or if these be objected to, 
the ordinary emetic of ipecacuanha, either alone or combined with 
tartarized antimony. Willan cautions us to avoid the latter salt, from 
its liability to operate too violently, and give rise to faintings. The 
employment of the emetic should be followed by a dose of castor-oil, 
or some simple cathartic ; and Plumbe recommends from twenty to 
forty drops of ether, to be given every half hour. 

Chronic urticaria calls for the use of aperients, counter-irritants, 
tonics, warm and cold baths, particularly the sponge bath and shower 
bath, careful attention to regimen, and the avoidance of all indigest- 
ible substances. I have derived the greatest amount of success in 
the treatment of chronic urticaria from the use of warm aloetic purga- 
tives, combined with the citrate of iron or nitro-muriatic acid in a 
bitter infusion or tincture, and afterwards followed by arsenic. The 
influence of dietetic substances was shown in the fact that, in one 
patient sugar was excommunicated with advantage, and in the same 
case great benefit was derived from the citrate of iron, at first com- 
bined with the hydriodate of potash, and subsequently with quinine. 
In another case, the infusion of serpentaria with carbonate of magnesia 
and carbonate of ammonia was completely successful. In a third, a 
course of sulphate of magnesia in drachm-doses, combined with car- 
bonate of magnesia and iodide of potassium, cured the patient after 



LICHENOUS OR PAPULOUS ERUPTIONS. 161 

other means had failed ; and in a fourth, five minims of the tincture 
of colchicum were usefully substituted for the iodide. I have also 
derived advantage from bismuth and from the oxide of silver ; the 
latter in one-grain doses a quarter of an hour before meals. Urticaria 
tuberosa is often so severe as to require depletion by venesection, and 
active antiphlogistic measures. Whenever urticaria assumes an inter- 
mittent form, it must be treated with bark or quinine, like ordinary 
intermittent fever. 

The intense itching and tingling which frequently accompany 
urticaria are best relieved by means of narcotics. Locally the lini- 
mentum saponis, with chloroform and laudanum, two drachms of each 
to the four ounces, is a valuable application. Acetous and alcoholic 
lotions, and lemon-juice, are sometimes useful for a similar purpose ; 
and a lotion composed of carbonate of ammonia and acetate of lead, 
of each a drachm, combined with eight ounces of rose-water,, has been 
recommended. I have found a lotion of chlorate of potash sometimes 
succeed in quelling the pruritus of this and ether eruptions ; but that 
upon which I chiefly rely is one composed of bichloride of mercury, 
from five to ten grains, spirit of rosemary and spirit of wine of each 
an ounce, and six ounces of the emulsion of bitter almonds. 

. If the eruption show a disposition to recede, or if it have already 
receded, blisters should be applied to the skin ; or the surface well 
rubbed with some stimulating liniment, such as that Of croton oil, in 
order to restore the eruption, or set up> an equivalent action in the 
skin. 



CHAPTER VI. 

DISEASES ARISING FROM GENERAL CAUSES. 
LICHENOUS OR PAPULOUS ERUPTIONS. 

In the present group of cutaneous affections, Lichen is taken as the 
typical form, just as Erythema is made to constitute the type of the 
preceding group. This group corresponds with the order Papulae of 
Willan, and the genus Exormia of Mason Good. It includes three 
affections, namely, 

Lichen. Strophulus. Prurigo. 

Rayer and Gibert remark that the above number might very pro- 
perly be reduced to two ; for that strophulus is nothing more than the 
lichen of young children and infants, while Alibert considers the whole 
under the single genus Prurigo. 

The definition given by Willan of the elementary form of papular 
affections admits of no improvement. A papula or pimple is " a very 
small and acuminated elevation of the cuticle, with an inflamed base, 
very seldom containing a fluid, or suppurating, and commonly termi- 

11 



162 DISEASES ARISING FROM GENERAL CAUSES. 

nating in scurf." Papulae terminate by resolution, generally with fur- 
furaceous desquamation of the epidermis. The papulae of strophulus 
have usually a greater elevation than those of lichen and prurigo. 
Pome differences are perceived also in relation to color ; thus, the pim- 
ples of strophulus may be either red or pale, those of lichen are always 
more or less red and inflamed, while the papulae of prurigo scarcely 
differ in tint from the surrounding skin. 

The seat of morbid action in the lichenous eruption is the vascular 
boundary of the various excretory tubules of the skin ; for example, 
the sudoriferous and sebiferous ducts, and hair-follicles. In this fact 
we have an explanation of various of the phenomena which accompany 
the eruption ; for example, the frequent perforation of the pimples by 
a hair, the formation of a thin scale upon the summit of the papule, 
the occasional appearance of a minute aperture in this situation, and 
the oozing of a transparent and colorless fluid from the same point. 
We can also better understand the provoking itching which is a symp- 
tom of the eruption, the obstruction which is offered to the escape of 
secretions, and the obstinacy of these disorders. The papulae of 
prurigo are perfectly identical with the papulae of lichen, the difference 
between them being, that the latter are generally acute in their course, 
while the former are always chronic. But there is an appearance of 
the skin in prurigo that must be familiar to all who are conversant 
with cutaneous diseases ; an unevenness of surface, produced by 
numberless slight but broad elevations, separated from each other by 
the linear markings of the skin. These are the elevations which have 
been described by all dermatologists under the name of the broad and 
flat papulae of prurigo. " Soft -and smooth papulae, somewhat larger 
and less acuminated than those of lichen, and seldom appearing red or 
inflamed, except from violent friction. Hence an inattentive observer 
may overlook the papulae altogether." 1 Rayer speaks of them as 
being " soft to the touch, and broader than those of lichen, from which 
they also differ in preserving the natural color of the skin." "They 
occasionally project in so slight a degree that they appear to be 
situated rather in the substance than on the surface of the skin." 
Now there is an evident obscurity about these descriptions, a contra- 
diction, in fact, which must have involved many in perplexity with 
regard to the real meaning of the authors. Papulae, precisely defined, 
broad, soft, smooth, and large, and yet not distinguishable in color 
from the adjacent skin, easily overlooked, and suggesting to the 
practised eye some uncertainty as to whether they were in or upon the 
skin. I will endeavor to explain the difficulty. 

As a consequence of the altered nutrition and innervation of the 
skin which accompany prurigo, the dermal tissues become changed 
in structure, namely, condensed and thickened. The most careless 
examination is sufficient to establish these two points ; the skin feels 
hard, it moves like a piece of thick leather ; the areae included between 
the lines of motion are large; its natural suppleness is gone; its very 
color is changed ; it looks yellowish and dirty. But it is smooth ; 

1 Bateman, Synopsis, third edition, p. 15. 



LICHENOUS OR PAPULOUS ERUPTIONS. 163 

there are no such projections as we should call pimples, or if there be, 
they are few and scattered. Arrived at this point, there remains but 
one conclusion for the student. There are no papulae, therefore the 
disorder cannot be prurigo. And yet the disease is so characteris- 
tically prurigo, that, setting aside the symptom of pruritus, the derma- 
tologist is enabled to decide at once upon its name. 

What, then, are the signs by which prurigo is so immediately 
distinguished? They are the thickening and condensation of the 
skin, and the consequences of this condition. Upon close exami- 
nation, the angular arese included by the linear markings of the skin 
are seen to be raised above their natural level, the elevation being 
occasioned by the thickening of the derma. That this is the case is 
evident from the position of the pores, namely, in the furrows which 
constitute the linear marking, and at the point of divergence of 
several of these. The elevations, therefore, are simply the effect of a 
swollen state of the derma, the arese being magnified by hypertrophy, 
and the linear markings being magnified in depth by the same cause. 
These swollen arese are the so-called papulae, the broad, and flat, and 
smooth papulae. It is not, then, to be wondered at, that they should 
be with difficulty discerned, that they should be " overlooked," seeing, 
as I have shown, that they are not papulae at all. 

But we do meet with papulae in prurigo, although not a necessary 
feature of that disease. These papulae are not the areae of the linear 
markings of the skin ; they occupy the grooves of the linear markings. 
They are, in fact, the pores raised into pimples, and are identical with 
the pimples of lichen. It is these latter which generally suffer abra- 
sion of their tips from scratching, and then become surmounted by a 
small, dark-colored scab. 

LICHEN. 

Syn. Exormia lichen, Mason Good. Lichenous rash. 

■ Lichen (Plate XL) is an eruption of minute conical papulae distri- 
buted upon a single region, or over the entire surface of the body. 
The pimples are comparable in size to millet seeds ;. they are reddish 
in color, or scarcely different from the natural hue of the skin, and are 
attended with itching, tingling, and smarting. They are usually 
developed in clusters, and appear in single or successive eruptions. 
They are non-contagious, and terminate in resolution and furfuraceous 
desquamation, sometimes in superficial ulceration. 

The appearance, situation, form, and severity of the disease, have 
given rise to its division into nine described varieties, which may with 
advantage be reduced to six, the other three, namely, lichen lividus, 
lichen pilaris, and lichen gyratus, being mere modifications of varieties. 
The six which remain are : 

Lichen simplex. Lichen urticatus. 

" annulatus. " tropicus. 

" circumscripta. " agrius. 



164 DISEASES ARISING FROM GENERAL CAUSES. 



LICHEN SIMPLEX. 

In the simple form of lichen (Plate XL, a), the pimples are dis- 
tributed irregularly over the surface affected, forming little patches 
from point to point, in which the papulae are more numerously assem- 
bled than in neighboring parts. Simple lichen is usually a chronic 
disorder, but occasionally presents itself in an acute form. The 
acute variety is preceded and accompanied by febrile symptoms, 
which are referable to the disordered state of the system, and are 
relieved by the outbreak of the eruption. 

In the acute form of lichen/ the eruption is ushered in by some 
degree of smarting and pruritus, Avhich are increased towards night; 
the papulae are red and inflamed, and continue hot and itchy for 
several days. In the course of three or four days the redness begins 
to subside, the pruritus diminishes, and the papulae decline; vanishing 
altogether at the end of a week or ten days, and being succeeded by 
furfuraceous desquamation of the epidermis. 

In the chronic form of the disorder the papulae are less red and 
inflamed. Individually, they run the same course of about a week 
or ten days, but being followed by successive crops, the eruption is 
prolonged for several months, and even years. By the continuance 
of irritation the skin becomes thickened, and throws off a copious 
furfuraceous desquamation, which is especially abundant in the flexures 
of joints. 

Willan remarked some modification in the appearance of the 
papulae according to the region in which they are developed. Thus 
on the face, papulae are large and rounded in form ; on the neck, 
trunk, and limbs, they are small, more vivid in color, and acuminated, 
and on the hands they are somewhat paler than in other situations. 

The ordinary seat of the acute variety of lichen simplex is the face 
and trunk of the body. The chronic form of the disease appears to 
attack by preference the backs of the hands, fore-arms, and arms ; and 
on the lower limbs, the hams and ankles. 

Lichen simplex has received the name of lichen lividus, when, 
from its occurrence in persons of weakly and debilitated constitution, 
or in those who are ill-fed, badly clothed, and live in unhealthy and 
confined situations, the pimples have a bluish and livid appearance. 
It is commonly met with among the squalid inmates of our work- 
houses at the period of admission, and is unaccompanied with 
constitutional disturbance. The papulae of lichen lividus are soft 
and somewhat flattened, they have a purplish red or livid hue, are of 
Longer continuance than those of simple lichen, and are developed on 
the arms and legs, but chiefly on the latter. Not unfrequently they 
are intermingled with petechiae, and small purple blotches and 
ecchymoses. The eruption is frequently prolonged by successive 
eruptions for several months. 

1 Portraits of Diseases of the Skin, Plate IX, Q. Tliis rase is curious from being so 
exactly limited in extent l>y a woollen vest which the patient wore. The clustered or 
corymbose distribution of the pimples on the arms is also interesting. 



LICHENOUS OR PAPULOUS ERUPTIONS. 165 

Lichen pilaris (Plate XL, b) is a term which is applied to lichen 
simplex, when the pimples are developed around the mouths of the 
pores by which the hairs issue from the skin. They are red and 
inflamed, extend deeply into the follicle, give rise to much tingling 
and itching, and are chronic in their course. The pimples usually 
decline at the end of a week or ten days, and terminate by furfuraceous 
desquamation of the epidermis, but are sometimes prolonged by suc- 
cessive eruptions to several months or years. This form of lichen 
occurs in persons of unsound and irritable constitution, and is 
frequently coincident with disorder -of the stomach and bowels, and 
the abuse of spirituous drinks. 

LICHEN ANNULATUS. 

Syn. Lichen annulatus $olitariu,s. Lichen annulatws serpiginosus. 
Erythema marginatum, Bateman. Lichen margiyiatus. Lichen 
gyratus, Biett. 

There is a variety of lichen, in which the disease commences as a 
mere spot, and increases rapidly in size until it forms a distinct ring. 
There is generally but one such ring on the whole body ; and the 
eruption may therefore be properly designated lichen annulatus 
solitarius. 1 The existence on the same person of more than two or 
three of these rings, is an exceptional occurrence. It is an eruption 
more frequently met with in women and children than among men, 
and the ring, after attaining a certain size, remains stationary, for 
two, three, or four weeks, and then disappears. The boundary ring 
in lichen annulatus presents some variety in point of elevation and 
degree of papulation. Sometimes the elevation is so trifling as 
scarcely to be perceptible ; at other times it is strongly marked ; 
usually the ring is formed by a line of well-developed papules, 
sometimes a double row, while often it is an almost uniform ridge. 
The want of clear definition of the papules, and the appearance of the 
area of the ring, which is yellowish and mealy, have caused it to be 
described under the name of erythema (Plate VII., l), but its proper 
place is the present group. 

The ring in lichen annulatus is of a lightish red color, with here 
and there a more vivid tint, from the presence of a papule of a brighter 
hue than the rest. The area presents a yellowish tint, and is covered 
with a mealy scurf; it is for the most part uniform, but occasionally 
has a few papules sprinkled on its surface, and sometimes includes a 
series of two or three concentric papular rings. (Plate VII., M.) 
Lichen annulatus solitarius is frequently associated with trichosis fur- 
furacea, or common ringworm, and is, in fact, the ringworm of the 
hairless skin. But it is also found where no ringworm of the scalp is 
present. 

Lichen annulatus SERPiaiNosus 2 is another form of the annulate 

1 Portraits of Diseases of the Skin. Plate XI., AI. In this plate several varieties of 
eruption are shown. This eruption is not (infrequently associated with common ringworm, 
and is, in fact, the so-called "ringworm of the body.' 

* Portraits of Diseases of the Skin, Plate X., AD. 



166 DISEASES ARISING FROM GENERAL CAUSES. 

variety of lichen ; its special characters being, the development of 
rings in considerable numbers, generally upon the breast or back ; 
and the rapid spreading of the rings, so that thej run together, and 
form one broad and extensive patch, upon and around which the more 
or less complete or interrupted markings of its component circles may 
be traced. This eruption is attended with very considerable itching, 
is chronic in its nature, and is succeeded by a mealy exfoliation of the 
epidermis. 

The eruption commences by lichenous pimples, which, subsiding at 
the summit and spreading at the base, are speedily converted into 
small, flat, erythematous disks, bounded by a sharp and distinct mar- 
gin. These disks, about half an inch in diameter, throw up at their 
edges, at one, two, or three points, several bright red pimples, and, 
increasing in size to the diameter of one or two inches, are converted 
into rings. When the centrifugal growth is equally active on all 
sides, the ring remains circular, and the margin is formed by a row of 
pimples more or less complete ; sometimes the row of pimples is 
broken at several points, sometimes they are ranged only on one side 
of the circle, and at other times they are entirely absent, and the mar- 
gin is formed by a simple ridge, along the summit of which the cuticle 
has become fissured (erythema marginatum). Bateman observes, that 
" the erythema marginatum occurs in patches, which are bounded 
on one side by a hard, elevated, tortuous red border, in some places 
obscurely papulated; but the redness has no regular boundary on the 
open side." When the pimples are developed only on one side of the 
circle, so as to form a crescentic rim, the ring is apt to increase chiefly 
by this side, and becomes more or less oblong ; and when the pim- 
ples constitute several broken rows, the ring is still more irregular. 
Increasing in this way, and by a portion only of the periphery of the 
ring, the rest of the ring is apt to be lost, and then only a portion of 
the margin remaining, the title of lichen mar g hiatus is not inapplicable. 
Or, when portions of several circles are more or less connected with 
each other, so as to form. an uneven line of some extent, we find an 
explanation of the term lichen gyratus, assigned by Biett to a narrow, 
tortuous band composed of lichenous papules. 

The area of the rings has a yellowish tint of color, and the cuticle 
covering it is slightly corrugated and dry, and sometimes the seat of 
a mealy exfoliation. In other respects, the area is uniform and 
smooth, and rarely presents any trace of pimples. Along the line of 
the margin, on both sides of the base of the papular ridge, the cuticle 
is commonly broken, and presents a thin, free edge. 

LICHEN CIRCUMSCRIPXUS. 
Clustering lichen. 

Lichen circumscriptus (Plate XL, E f) differs from lichen simplex 
only in the mode of aggregation of the pimples. They are collected 
into one or several patches, of a circular or oval form, and bounded 
by a well-defined margin, consisting generally of the largest and most 
inflamed papulae. The patches in the first instance appear as small 



LICHENOUS OR PAPULOUS ERUPTIONS. 167 

aggregated clusters, which progressively increase by their circum- 
ference, while they exhibit a tendency to fade in the centre, and form 
rings of variable size. In the latter case, the boundary of the ring 
maintains a certain breadth, and forms a kind of ribbon or belt around 
the included area, in which a greater or less number of pimples con- 
tinue to be developed. 

When the ribbon or belt is broken in its circle, or parts of several 
circles are irregularly connected together, we have the variety de- 
scribed by Biett under the name of lichen gyratus, which consists in 
the aggregation of the papula into one or several narrow and tortuous 
bands of variable length. Cazenave and Schedel observe, " We have 
lately seen an instance of this disease in the hospital Saint Louis ; the 
papulae collected into little groups, formed a kind of ribbon, which, 
commencing on the front of the chest, curved downwards along the 
inner border of the arm, and continued onwards, precisely in the di- 
rection of the course of the ulnar nerve, to the little finger." Bayer 
remarks, that he has seen it form " a kind of collar in front of the 
neck, extending from one ear across to the other." 

LICHEN URTICATUS. 
Lichen urticosus, Mason Good. 

In lichen urticatus (Plate XI., d), a variety described by Bateman, 
the papulae are of a larger size than in other forms of the disease. They 
are inflamed and prominent, and resemble, at their first appearance, 
the bite of a gnat or bug. They generally show themselves suddenly, 
and disappear, unless irritated by scratching, in the course of a day. 
More frequently, however, from the burning heat and pungent itching 
which attend them, they are scratched and bleed, and a small black 
crust is formed upon their summits. The disease seems to be peculiar 
to children, and is remarkable for its obstinacy. The following case 
is an illustration of this disorder : 

A little girl, three years and a half old, delicate, but healthful in 
her functions, has been subject to an eruption, attended with itching, 
since, the age of ten months. In January, 1846, she had measles, and 
since that period the attacks of the cutaneous disorder have been more 
frequent. The eruption shows itself in the form of large red pimples, 
generally isolated, but frequently in clusters, particularly on the face, 
neck, and shoulders. The pimples are excited by warmth; for ex- 
ample, by the warmth of bed, so that she is sometimes awakened in the 
night by the itching. They are also excited by mental emotion ; thus, 
if she be scolded, the itching begins ; and, to use her mother's expres- 
sion, she can at all times "rub them up wherever she likes." When 
left to themselves, the pimples subside in the course of twenty-four 
hours ; but when scratched, a little blood oozes from their summits, 
and desiccates into a small black scab. On some of the pimples a 
little pus forms at the points ; and on the soles of her feet they run 
into a vesicular form. Each pimple, when it does not subside at once, 
continues for about a fortnight ; but as fresh ones are continually 



168 DISEASES ARISING FROM GENERAL CAUSES. 

appearing, the eruption has now been prolonged without amendment 
for three months. 

Such was the state of the case when I first saw her. I prescribed 
for her citrate of iron, with hydriodate of potash, and a lotion of 
bichloride of mercury in an emulsion of bitter almonds, five grains to 
the half pint. The lotion relieved the itching, but the eruption con- 
tinued unchanged, although the child was obviously improved in 
health. I then had recourse to quinine, with nitric acid ; but finding 
no amendment at the end of another fortnight, I prescribed for her one 
grain of chloride of mercury, with two of nitrate of potash, twice in 
the day. Nothing, however, seemed to produce an impression on the 
disease, and I was glad to avail myself of an opportunity of sending 
her into the country, to try the effect of change of air. 

LICHEN TROPICUS. 

Syn. Essera, Eshera, Arabic. Summer rash. 

Lichen tropicus, or prickly heat, Ls the usual form of this eruption 
when it occurs in warm climates. Willan gives an excellent descrip- 
tion of the disease, in a communication by Dr. Winterbottom. From 
this account the following passages are selected : 

"The prickly heat appears without any preceding disorder of the 
constitution. It consists of numerous papulae, about the size of a 
small pin's head, and elevated so as to produce a considerable rough- 
ness of the skin. The papulae are of a vivid red color, and often 
exhibit an irregular form, two or three of them being in many places 
united together, but no redness or inflammation extends to the skin in 
the interstices of the papulae." 

"The eruption is diffused over those parts of the body which are 
usually covered, as the neck, breast, arms, legs, and inside the thighs. 
It does not often appear on the face, excepting on the upper part of 
the forehead, contiguous to the hair: neither is it ever found in the 
palms of the hands, soles of the feet, nor on the hairy scalp. The 
number of the papulae is much increased by wearing flannel, or clothes 
too warm and thick for the climate. When perspiration is very 
copious, small vesicles containing a limpid humor are often inter- 
mingled with the prickly heat, more especially on the breast and 
about the wrists ; but they terminate in scales, having no disposition 
to ulcerate, though violently scratched. A troublesome itching 
attends the prickly heat, and prevents sleep during the night. There 
is likewise a frequent sensation of pricking, as if a number of pins 
were piercing the skin. This often takes place suddenly after drink- 
ing a dish of tea, or any warm liquor, so as to cause the person 
affected to start from his seat. The eruption is in general stationary, 
and appears equally vivid in the day and in the night. It does not 
leave one part and arise on another, unless the former be much 
exposed to cold, and the latter be heated by additional clothing, or by 
friction. An increase of heat, indeed, in all cases, produces a greater 
number of papulae. They sometimes disappear on a sudden, and 
return again as suddenly, without any obvious cause ; but whenever 



LICHENOUS OR PAPULOUS ERUPTIONS. 169 

the eruption continues for a length of time, the papulae throw off 
minute scales, and are succeeded by a fresh crop, no vestiges being left 
in the skin. The prickly heat is in general considered as a salutary 
eruption, whence we are cautioned not to repel it from the skin by 
cold or other external applications. Such a repulsion cannot, how- 
ever, be easily effected ; it is certainly not produced by bathing, 
which has been hitherto thought highly prejudicial. A vivid erup- 
tion of the prickly heat is a proof that the person affected with it is in 
a good state of health, although its absence does not always indicate 
the contrary. The sudden disappearance of it which frequently hap- 
pens, is rather an effect than a cause of internal disorder, as of fever, 
or of any slight complaint of the stomach; in the latter case, a tempo- 
rary stimulus, applied to the stomach, as by spirits, tea, or other warm 
liquids, has the power of restoring the eruption. Its appearance on 
the skin of persons in a state of convalescence from fevers, &c, is 
always a favorable sign, indicating the return of health and of vigor." 

"Various means have been employed to alleviate the itching and 
tingling of the prickly heat; the favorite remedy at Sierra Leone is 
the juice of limes rubbed on the skin, which, however, has no con- 
siderable effect. I have found it of most advantage to use a light, 
cool dress, and to avoid the drinking of Avarm liquors." 

Dr. James Johnson, who was a sufferer from the prickly heat, gives 
the following animated description of the disorder: "This unwelcome 
guest assails us at all, and particularly the most unseasonable hours. 
Many a time have I been forced to spring from table, and abandon 
the repast which I had scarcely touched, to writhe about in the open 
air for a quarter of an hour ; and often have I returned to the charge 
with no better success against my ignoble opponent. The night affords 
no asylum. For some weeks after arriving in India I seldom could 
obtain more than an hour's sleep at one time, before I was compelled 
to quit my couch with no small precipitation, and if there were any 
water at hand, to sluice it over me, for the purpose of allaying the 
inexpressible irritation. But this was productive of temporary relief 
only, and what was worse, a more violent paroxysm frequently suc- 
ceeded." 

" The sensations arising from prickly heat are perfectly indescrib- 
able, being compounded of pricking, itching, tingling, and many other 
feelings for which I have no appropriate appellation." 

"It is usually, but not invariably, accompanied by an eruption of 
vivid red pimples, not larger in general than a pin's head, which 
Bpread over the breast, arms, thighs, neck, and occasionally along the 
forehead. This eruption often disappears in a great measure when we 
arc sitting quiet, and the skin is cool, but no sooner do we use any 
exercise that brings out a perspiration, or swallow any warm or 
stimulating fluid, such as tea, soup, or wine, than the pimples become 
elevated, so as to be distinctly seen, and but too sensibly felt." 

In reference to the imagined dangers of repelling this eruption, Dr. 
Johnson continues: "Indeed, I never saw it even repelled by the cold 
bath ; and in my own case, as well as in many others, it seemed rather 
to aggravate the eruption and disagreeable sensations, especially during 



170 DISEASES ARISING FROM GENERAL CAUSES. 

the glow which succeeded immersion. It certainly disappears suddenly 
sometimes on the accession of other diseases, but I never had reason 
to suppose that its disappearance occasioned them. I have tried lime- 
juice, hair-powder, and a variety of external applications, with little 
or no benefit ; in short, the only means which I ever saw productive 
of any good effect in mitigating its violence, till the constitution got 
assimilated to the climate, were light clothing, temperance in eating 
and drinking, avoiding all exercise in the heat of the day, open bowels, 
and last, not least, a determined resolution to resist with stoical 
apathy its first attacks. To sit quiet and unmoved under its pressure 
is undoubtedly no easy task ; but if we can only muster up fortitude 
enough to bear with patience the first few minutes of the assault 
without being roused into motion, the enemy, like the foiled tiger, 
will generally sneak, and leave us victorious for the time." 

The author very truly observes, that an affection similar to lichen 
tropicus is sometimes seen during the summer season in this country. 
I have myself suffered from its annoying attack on one or two occa- 
sions, and can add my testimony to that of Dr. Johnson. 

LICHEN AGRIUS. 

Syn. Lichen eczematosus, vel ichorosus. Lichen fer us. 
Agria, Grsecorum. 

Lichen agrius (Plate XI., G h) is the most intense, and when exten- 
sive, a very severe form of lichenous disease ; the papula are acu- 
minated and prominent, of a vivid red color, and numerous ; they are 
aggregated into clusters of irregular form and size, are attended with 
much heat, smarting, and itching, by a painful sensation of tension, 
and are surrounded by considerable inflammation. 

These symptoms continue to increase for several days, when the less 
inflamed papulre diminish in redness, and become covered with a fur- 
furaceous desquamation. The more inflamed papulge, however, and 
especially those which are collected into clusters, have their points 
torn off by friction or scratching, and form small superficial abrasions, 
which pour forth an ichorous or sero-purulent fluid, and this secretion 
desiccates into thin yellowish crusts. The skin around the papulae is 
at the same time thickened by the continuance of the inflammation, 
and fissured by deep cracks, from which a copious watery secretion 
exudes. In milder cases the disease subsides before reaching this 
extreme, the redness and painful symptoms diminish, and the eruption 
dies away in two or three weeks. 

In the severe form, as soon as the crust falls off and desquamation 
occurs, new papulte are developed, which pursue the same course as 
their predecessors, and the disease is prolonged to several weeks, or 
months; at other times, the eruption appears and disappears several 
times in succession before a cure is accomplished. 

More commonly, the eruption is of chronic origin ; it begins as a 
small patch of irritable pimples, say on the back of the hand; these 
pimples are very irritable, they are rubbed or scratched, and next 
day more pimples are developed. This process may go on for several 



LICHENOUS OR PAPULOUS ERUPTIONS. 171 

weeks, the pimples sometimes glowing and sometimes fading ; until, 
without any apparent cause, the patch suddenly becomes as large as 
a half-crown piece, and establishes itself as a permanent eruption. 

Lichen agrius is generally partial in its eruption, being confined to 
one or more regions. It is most frequently seen upon the arms, the 
hands, the shoulders, the loins, the legs, as also upon the chest and 
face. On the backs of the hands it constitutes the bricklayer's, 
grocer's, baker's, and washerwoman's itch of Willan and Bateman. 1 
The itching and smarting are sometimes intolerable, generally periodic, 
and much aggravated towards the evening, or by the warmth of bed, 2 
exercise, stimulating food, and drink, &c. Occasionally the papulae 
are intermingled with small vesicles or pustules, which speedily burst, 
and terminate by desquamation. 

The eruption very commonly takes place without any constitutional 
symptoms ; or, if such be present, they have no special reference to 
the invasion of the disorder. Generally they are only of a kind 
indicating dyspepsia, such as acidity and flatulence, with a sense of 
heaviness and debility ; sometimes accompanied with neuralgic, rheu- 
matic, or gouty pains. At other times the constitutional symptoms 
are more severe : for example, rigors, flushes of heat, lassitude, pains 
in the limbs, headache, nausea, pain at the epigastrium, white, furred 
tongue, and quick pulse. These symptoms make their invasion for 
several days previously to the appearance of the cutaneous affection, 
and are, for the most part, relieved by its eruption. When the disease 
has been suddenly checked, some visceral derangement has generally 
taken its place. 

Diagnosis. — The diagnostic characters of lichen are, its solid and 
prominent pimples, the coloration of these pimples, and their attendant 
itching, which is of the tingling kind. The diseases with which it 
may be confounded, are the pruriginous affections : prurigo, scabies, 
and eczema. In prurigo, however, the papulae are paler than those 
of lichen, and there is a general unhealthiness of appearance, and 
oftentimes a disorganization of the skin. The little black scabs which 
surmount the papulae of prurigo when torn by the nails, and the 
scratches by which the skin is marked, must also be borne in mind. 
Scabies resembles lichen only in the presence of itching, but this is 
different in its character; moreover, it may be remarked, that lichen 
selects by preference those parts of the body in which the derma is 
thickest, as the back, the face, and the outer sides of the limbs, whilst 
the regions furnished with the thinnest skin are those affected by 
scabies. Eczema, it will be recollected, is a vesicular or ichorous 
eruption, and therefore distinct from the solid, dry papulae of the 
disease under consideration. When the points of the papulae of lichen 
are torn off, the crusts which succeed are thinner and more scale-like 
than those of eczema. 

1 Portraits of Diseases of the Skin ; Plate XII., G., represents a case of Lichen agrius 
dorsi mantis. 

2 Plumbe remarks, that the parts smart for an hour or more, as if they "had been 
severely scalded, ' 



172 DISEASES ARISING FROM GENERAL CAUSES. 

Lichen circumscriptum bears some resemblance in the form of the 
patch to erythema circinatum, erythema marginatum, and herpes 
circinatus, but from these the diagnosis is by no means difficult. In 
erythema circinatum, the surface is smooth ; in erythema marginatum, 
although raised and papulated, there are no scattered papulse in the 
neighborhood of the patch ; while in herpes there are vesicles, or their 
detrita, and a greater degree of redness. 

Lichen urticatus differs from urticaria in the irregularity of form 
and size of the papulae, their greater redness and chronic character; 
and from erythema papulatum, by the small and irregular patches of 
the latter being merely papuloid, by their inferior degree of redness, 
and by the comparative absence of pruritus. 

Lichen agrius is especially characterized by the close aggregation 
and highly inflamed state of the pimples, by the severe smarting and 
tingling, by scaly erusts, the superficial excoriations, the fissures and 
chaps which so frequently form, and by the thickening and condensa- 
tion of the integument. 

Causes. — Lichen occurs in persons of every temperament, and at 
all periods of life. It is most frequently observed in the spring and 
summer season, and especially in the latter. Increased temperature 
appears to have a certain influence in producing the disease, as we 
see evinced in lichen tropicus, or prickly heat ; for the same reason 
the eruption is met with on the arms and face of persons employed 
near the fire, as of cooks and smiths. Local irritation is not unfre- 
quently an exciting cause, in persons of irritable skin, from the use of 
flannel or woollen raiment, or coarse body linen. Other exciting causes 
are, depressing moral or physical conditions, excessive fatigue, irregu- 
larities of diet, intemperate habits, &c. Sometimes it appears critically 
in fevers, and in acute or chronic visceral affections. 

Lichen agrius would seem to be most frequent in elderly persons, 
females, and young persons of sanguine or nervous temperament. It 
is usually referable to fatigue, anxiety, or dyspepsia, and is a frequent 
accompaniment of the rheumatic and gouty diathesis. But the most 
troublesome cases of lichen agrius with which I have had to contend, 
have occurred upon the legs of men who had passed the mid-period 
of life. These cases were all accompanied with oedema, and sometimes 
with varicose veins. 

Prognosis. — Lichen is not dangerous to life, but is often exceed- 
ingly troublesome. That which originates from the more simple 
causes in young persons, and pursues an acute course, generally termi- 
ng tcs in two or three weeks, but the chronic kinds may last for years. 
Lichen of the face is especially obstinate. 

Treatment. — Simple lichen requires a treatment directed upon 
ordinary antiphlogistic principles; with, locally, a tepid bath, or 
lotions containing liquor plumbi diacetatis, distilled vinegar, or lemon- 
juice, to subdue the local irritation. 

In more chronic forms of the eruption a purgative is always indi- 
cated, while attention should be bestowed on the secretions of the 
liver, kidneys, and skin, and the bowels regulated. 

Lichen agrius is essentially a disease of the assimilative functions ; 



LICHENOUS OR PAPULOUS ERUPTIONS. 173 

and its frequent association with the rheumatic and gouty diathesis 
must be borne in mind. Antacid purgatives, with diuretics and 
diaphoretics ; warm purges of rhubarb and aloes, combined with diu- 
retics ; or, if the indication be obvious, with colchicum ; with lemon- 
ade for drink — are the class of means to be employed. Sometimes a 
specific course of diuretics is attended with successful results. But 
the practitioner is often put upon his mettle by this disease, and must 
use considerable ingenuity to foil the adversary. In females I have 
found the mistura ferri composita, with decoctum aloes compositum, 
and liquor potassse, an admirable remedy. As soon as it appears 
judicious to stop the purgative plan, alteratives and tonics come into 
play ; and, in a very chronic state of the disease, the special cutaneous 
alteratives, Donovan's, Fowler's, and De Valangin's solutions. 

The activity of treatment in lichen agrius must, of course, be regu- 
lated by the severity and extent of the eruption. 

Lichen lividus is to be managed by an alterative and tonic plan of 
treatment, after a preliminary clearance of the alimentary canal. 

The local treatment of lichen agrius consists in the judicious selec- 
tion and application of lotions and ointments; in the first instance, to 
calm the surface while the general remedies act upon the blood ; and 
secondly, to modify the local disease when it merges into a chronic 
form. The best lotions for the former purpose are, the saturnine 
spirit lotion, with camphor or vinegar; a lotion containing the sesqui- 
carbonate of ammonia and liquor plumbi; if the itching be severe, a 
lotion of hydrocyanic acid; or if there be ichorous discharge, a weak 
spirit lotion containing one or two drachms of the oxide of zinc to the 
half-pint. The best ointments for the same purpose are — ceratum 
cetacei, with a drachm of liquor plumbi to the ounce; the oxide of zinc 
ointment, either alone or in combination with liquor plumbi or spiritus 
camphorse; calamine ointment; or oleaginous compounds of almond 
oil, lime-water, and liquor plumbi, oxide of zinc, or trisnitrate of bis- 
muth. 

There has been a fashion of late — and fashions in medicine are 
always false and dangerous — to abuse ointments; "greasy" applica- 
tions, as they are universally called. They are, nevertheless, most 
essential in the treatment of cutaneous complaints ; and when they 
irritate or inflame the skin, the fault is not in the pure ointment, but 
in the rancidity or otherwise decomposed quality of the substance 
employed. Ointments are valuable as agents preventing the hyper- 
oxygenization of the blood which occurs in all cutaneous inflamma- 
tions, and which has of late rendered lard so conspicuous as a remedy 
for exanthemata, small-pox, and erysipelas. Lotions, on the contrary, 
unless they be kept constantly applied, are followed by desiccation of 
the skin, and a consequent increase of irritation of the eruption. There 
is one substance, however, which may be combined with any form of 
lotion, and is an exception to this law, namely, glycerine. Glycerine 
maintains a permanent state of moisture of the surface; and where 
ointments, in peculiar idiosyncrasies, or under particular circumstances, 
cannot be borne, glycerine will be found to be an efficient and useful 
substitute. It may be applied either in its concentrated form or in a 



174 DISEASES ARISING FROM GENERAL CAUSES. 

state of dilution ; and, if there be no abrasion of the skin, is unirritant, 
and a mild and soothing remedy. 

When the purpose of local treatment is to modify the morbid action 
taking place in the skin, the lotions and ointments best suited to the 
case are, a lotion of bichloride of mercury in almond emulsion, or in 
simple solution with the hydrochlorate of ammonia; a lotion contain- 
ing creasote ; or pencilling with the tincture of croton, or compound 
tincture of iodine. The ointments are, unguentum hydrargyri am- 
monio-chloridi ; the nitrate of mercury ointment, pure or diluted ; the 
nitric oxide of mercury ointment, pure or diluted ; calomel ointment ; 
the ointment of the deutioduret of mercury, ten grains to the ounce; 
the ioduret of sulphur ointment, also ten grains to the ounce; or the 
unguentum hydrargyri ; the force of these remedies being augmented, 
if requisite, by the addition of friction. 

I cannot say that I have seen any advantage result from the use of 
collodion in this complaint. 

STROPHULUS. 

Syn. Enormia strophulus, Mason Good. Tooth-rash. Red gown. Red 
Gum rash. Gum rash. 

Strophulus (Plate XI.) is a disease of early infancy, consisting in 
the eruption of small pimples upon part, or upon the whole surface of 
the body. The pimples are usually red, but sometimes paler than the 
surrounding skin; they are attended with itching, which is increased 
by warmth; but they give rise to little constitutional disturbance, and 
terminate by resolution and epidermal desquamation. 

The appearance 1 , distribution, and color of the pimples of strophulus 
have given rise to its division into five varieties, namely, 
Strophulus intertinctus, Strophulus albidus, 

" confertus, " candidus. 

" volaticus, 

STROPHULUS INTERTINCTUS. 

Strophulus intertinctus (Plate XI., i) the red gum rash, or red gown 
of popular language, is an eruption of prominent pimples of a vivid 
red color, upon one or several regions of the body, or generally dis- 
posed over the entire surface, the eruption being intermingled with 
minute red points and erythematous patches of variable extent. The 
pimples remain upon the skin for some time, some disappearing, while 
fresh crops break forth, and the disease terminates, at the end of one 
or two weeks, by desquamation of the epidermis. Occasionally the 
strophulus appears at successive periods, being alternated by intervals 
of freedom from eruption. It is observed by Willan, that the pimples 
are developed principally on the cheeks, the backs of the hands, and 
the fore-arms; they are unaccompanied by symptoms of constitutional 
disturbance, and as frequently affect the strongest and healthiest as 
weakly children. Strophulus is usually coincident with acidity of 



. LICHENOUS OR PAPULOUS ERUPTIONS. 175 

stomach and intestinal disorder, both of which may depend, with the 
eruption itself, upon the irritation of teething. When the eruption has 
been repelled by exposure to cold or mismanagement, serious effects 
have been produced on the nervous system and alimentary mucous 
membrane. 

STROPHULUS CONFERTUS. 

Strophulus confertus, or tooth-rash (Plate XI., i), is a more severe 
variety than the preceding. The pimples are more numerous, and 
smaller in size ; they are aggregated into considerable patches, and 
are often confluent. Sometimes they are distributed generally over 
the surface of the body, but more frequently are confined to a single 
spot, or to several regions, as the face, the breast, or the arms. The 
redness of the pimples is less vivid but more lasting than that of stro- 
phulus intertinctus : the eruption usually attains its height in twelve 
or fourteen days, and then subsides, leaving a copious furfuraceous 
desquamation of the epidermis. Strophulus confertus, according to 
Willan, occurs at about the fourth or fifth month ; and frequently on 
its decline a fresh eruption succeeds. 

Another form of this disease is described by the same author as 
taking place in infants of seven or eight months. The pimples in this 
modification are collected into one, two, or three large and irregular 
clusters, which appear upon some one point, as upon the fore-arm, and 
thence extend, upwards and downwards, along the arm. The patches, 
as well as the intermediate skin, are of a deep red color, and are suc- 
ceeded by an extensive epidermal exfoliation ; the skin remains, for 
some time after, dry and harsh, and of a dull red color. 

This form of strophulus sometimes occurs upon the legs, and assumes 
a painful and obstinate shape. The eruption extends upwards along 
the thighs to the loins and abdomen, and produces a redness which is 
nearly continuous. The epidermis becomes dry, and cracks and sepa- 
rates in large flakes, leaving the integument beneath inflamed and 
rough. These symptoms, with considerable heat, pruritus, and irrita- 
tion, maybe prolonged for several months, or, as Willan remarks, they 
may continue until the infant completes its first year. 

The constitutional symptoms of strophulus confertus, as of the pre- 
ceding variety, are very slight, but the local pruritus is troublesome, 
and often severe. The disease is referable for its cause to the irrita- 
tion of teething, as is implied in its popular designation of tooth-rash. 

STROPHULUS VOLATICUS. 

Syn. Exormia volaticus. Erythema volaticum, Sauvages. JEstus 
volaticus. Feu volage. Wild-fire rash. 

This variety (Plate XI., k) is characterized by the eruption of papulae 
of a vivid red color, in small circular clusters, which arc scattered over 
the sui fare of the body. Each cluster contains from three to twelve 
papulae, which arc hot, and attended with itching. In a few days the 
inflammatory condition subsides, the pimples assume a brownish tint, 
and the eruption terminates by epidermal desquamation. More fre- 



176 DISEASES ARISING FROM GENERAL CAUSES. 

quently, however, new patches appear as the older ones decline, and 
the disease may be prolonged for several weeks. The patches of 
strophulus volaticus are particularly observed on the cheeks and arms. 
Strophulus volaticus is accompanied with general uneasiness and 
frctfulness, quick pulse, white tongue, and disordered bowels. 

STROPHULUS ALBIDUS. 

White gum-rash. 

In strophulus albidus (Plate XL, l) the pimples are white, and 
minute in size, each being surrounded by an areola of slight redness. 
They appear for the most part on the face, neck, and breast, and 
continue for a considerable time. They are not unfrequently inter- 
mingled with the red papulae of the preceding varieties. 

STROPHULUS CANDIDUS. 

Pallid gum-rash. 

In this variety (Plate XI., m) the papulae are of larger size, and 
broader than in any of the preceding forms ; they are hard, smooth,- 
and tense, and without accompanying redness. The pimples are 
scattered irregularly over the body, but are most strongly developed 
on the arms, shoulders, and loins. They subside at the end of the 
week, and then gradually disappear. This eruption occurs most com- 
monly in the later periods of dentition, and is sometimes observed 
during convalescence from inflammatory disorders. 

Diagnosis. — Strophulus is distinguished from other papular affec- 
tions chiefly by its occurrence at the infantile period of life. The 
papulae so closely resemble those of lichen as to appear identical with 
that disease. They are, indeed, modified only by the age of the subject 
in whom they are developed. 

Causes. — Strophulus is generally due to gastric and intestinal 
irritation, and is frequently associated with the constitutional disturb- 
ance induced by dentition. It occasionally arises from local causes, 
as from deficient, irritating, or coarse clothing, want of cleanliness, 
excess of or improper food, heat, &c., and is usually developed in 
children possessing a delicate and irritable skin. The eruption often 
alternates with attacks of gastro-intestinal irritation. As far as its 
prognosis is concerned, it is unattended with danger, and rarely 
presents any features of severity. 

Treatment. — "When the eruption obviously originates in local 
irritation, the acting cause should be removed, and frequent ablutions 
adopted. The tepid bath should be used frequently, together with 
emollient and sedative fomentations. The pruritus, which is so 
annoying a symptom in this eruption, may be relieved by a lotion of 
acetate of lead, or sulphate of zinc, by one containing the sesquicar- 
bonate of ammonia, acetic acid, lemon-juice, salt and water, or almond 
emulsion. When the eruption is dry and chapped, or when an 
ichorous secretion is poured out, the best application will be found 



LICHENOUS OR PAPULOUS ERUPTIONS. 177 

to be an ointment containing the liquor plumbi diacetatis, half a 
drachm to the ounce ; or the oxide of zinc_ ointment diluted with 
spiritus camphorae, a drachm to the ounce ; or, again, an ointment 
containing hydrocyanic acid or creasote, apportioning the strength 
according to the necessities of the case. If the disease be associated 
with gastro-intestinal irritation, it is desirable to avoid the possibility 
of repelling the cutaneous congestion by cold applications ; and where 
this has unfortunately been done, recourse must be immediately had 
to the warm bath, either simple, or medicated with a handful of 
mustard. 

When difficult dentition is the exciting cause, relief may be obtained 
by incising the gums. And if gastro-intestinal irritation be present, 
antacid and laxative remedies should be administered. Mercury with 
chalk and rhubarb, are valuable medicines in this state of the alimen- 
tary canal. 

PRURIGO. 

Syn. JExormia prurigo. Mason Good. Pruritus. 

' Prurigo (Plate XI.) is a chronic and non-contagious affection of the 
skin, characterized by a thickened and discolored state of that mem- 
brane, and by an excessive and burning pruritus. Moreover, this 
state of skin is generally accompanied with an eruption of isolated and 
scattered papulae, not differing in" color from that of the general sur- 
face. The thickening of the skin gives it a coarseness of character, 
and on close examination it is found raised into small flat elevations, 
caused by the swelling of the little angular compartments between the 
linear markings. It is also more or less streaked with scratches made 
by the finger nails, and the torn papulae are each surmounted by a 
small, thin, and black scab. The color of the skin is yellowish and 
dirty. The disease is unaccompanied by constitutional symptoms. 

The principal varieties of prurigo, as a general affection, are three 
in number; to which may be added several local forms. The general 
varieties are : 

Prurigo mitis, 

" for mi cans, 

" senilis. 

PRURIGO MITIS. 

In the milder form of prurigo (Plate XI., N n), the morbid change in 
the skin is less decided than in the severer kinds; but the pruritus is 
vexatious and annoying. It is brought on by mental emotion, the 
taking of food, or by change of temperature, and is augmented by 
scratching, by exercise, and the warmth of bed. The skin, which at 
first presented no appearance different from health, becomes by de- 
grees thickened, indurated, and coarse; the pimples, few in number at 
first, become numerous, many have their points torn off, and are sur- 
mounted by a small black crust; there are scratches here and there 
upon the skin ; it becomes yellowish and dirty ; and the epidermis is 

12 



178 DISEASES ARISING FROM GENERAL CAUSES. 

thrown off as a furfuraceous and pulverulent desquamation. Occa- 
sionally the extreme irritation produced by this eruption gives rise to 
the development of ecthymatous pustules. 

Prurigo mitis makes its appearance in the spring and summer 
months, without premonitory symptoms. It is developed upon every 
part of the surface of the body, but its more usual seat is the posterior 
surface of the trunk, the shoulders, the outer sides of the limbs, as of 
the arms and thighs, the chest, and sometimes the face. When the 
disease terminates mildly, it declines at the end of two or three weeks ; 
at other times the affection is prolonged for several months. 

PRURIGO FORMICANS. 

Prurigo formicans (Plate XI., N n) is a severe degree of prurigo 
mitis, differing from the latter in the longer duration of the disease, 
and in the greater violence of the pruritus. The itching is incessant, 
frequently insupportable, and accompanied by a most distressing sen- 
sation, compared, by the sufferers, to having their flesh devoured by 
thousands of ants, or to the piercing the skin with red-hot needles. 
Raver observes, that patients describing their suffering speak of heat 
of the blood, burning fires, maddening itchiness, &C. 1 It is increased by 
every alternation of temperature, particularly by the warmth of bed ; 
so that patients affected by this disease tear themselves cruelly with 
their nails throughout the entire night, and are totally unable to sleep 
until, towards the morning, they sink from exhaustion into forgetful- 
ness, or after a night of disturbed sleep are awakened with the first 
dawn by their unsparing tormentor. The violence of the scratching 
to which the sufferers so afflicted yield themselves, produces redness ol 
the skin, and by removing the heads of the papulae, gives rise to the 
formation of numerous small black scabs ; these little scabs, resulting 
from the oozing of a minute drop of blood from each of the wounded 
papulae, with intermingled scratches, are frequently the only indication 
of the disease. Prurigo formicans is very tedious in duration, extend- 
ing to several months, and sometimes, with intermissions, to years. 
At the termination of the disorder the skin remains dry and thick- 
ened, and the epidermis exfoliates by a furfuraceous and mealy des- 
quamation. 

Prurigo formicans is frequently associated with some visceral affec- 
tion, in which case it may be preceded and accompanied by febrile 
disorder. When suddenly repelled, serious symptoms have been seen 
to arise, and call for active treatment. The disease occurs both in 
children and adults, and at all seasons of the year. 

1 The Abbe Morellel was afflicted with this distressing disease at the advanced age of 
eighty year-. 1 1 obliged him to rise several times in the course of the night, to sponge his 
body with vinegar and water containing the acetate of lead. Writing to Alibert, he ex- 
pressed himself as writhing on the " gril de St. Laurent." A soldier, affected with the 
same disease, compared his sufferings to being pierced all over with halberds. Alibert 
records several distinguished men among those who have been afflicted with this perse- 
cuting malady, as Plato, Charles V., and Charles IX. 



LICHENOUS OR PAPULOUS ERUPTIONS. 179 



PRURIGO SENILIS. 

The prurigo of aged persons bears a close resemblance to prurigo 
formicans : but the disorganization of the skin is more complete, and 
the itching incessant. The disease is very obstinate, and frequently 
endures for years. 

u In severe cases," write Cazenave and Schedel, "the skin becomes 
swollen and inflamed ; eruptions of vesicles, pustules, and boils, appear; 
and sometimes abscesses are formed. Under such circumstances there 
are frequently symptoms of fever, restlessness, and sleeplessness, and 
sometimes indications of gastro-intestinal irritation, &c. Finally, in 
these serious and excessively rebellious cases, the patient is tormented 
with dreadful itching." In one very severe case of prurigo senilis, 
Willan discovered a number of minute pulices upon the skin, and he 
remarks upon the frequent association of the pediculus vestimentorum 
with the eruption; of course, he means among the lowest classes of 
persons. 

LOCAL VARIETIES. 
The principal local varieties of prurigo are three in number ; they 
are characterized by intense itching, and by the alteration of the 
dermal tissues above described as constituting the general affection. 
Willan describes, under this designation, several other forms of dis- 
tressing itching, which are unaccompanied by papulae, and are ascrib- 
able to an altered sensibility of the cutaneous nerves. I have there- 
fore thought it advisable to arrange the latter affections under the head 
of pruritis, and treat of them separately in a distinct section of the 
work. The local varieties of prurigo are — 

Prurigo podicis, 
" scroti, 
" pudendalis. 

Prurigo podicis consists in an alteration of the skin, similar to that 
already described, around the anus, and upon the neighboring regions 
of the perineum and thighs. The itching is severe and distressing, 
and increases at night, commencing shortly after the sufferer has 
retired to bed, and continuing incessantly for several hours. As a 
consequence of scratching, the papulae become covered by minute 
black scabs, which serve as a diagnostic character. This disease is 
exceedingly obstinate, and, unless relieved by treatment, will last for 
several months. After it has continued for some time the integument 
becomes much thickened. 

This form of eruption might be advantageously considered as a 
chronic lichen or chronic eczema, in short, a psoriasis. 

Prurigo scroti is frequently an extension of the preceding affec- 
tion ; the papulae are developed on the scrotum and root of the penis, 
and give rise to unappeasable itching. The patient, in making 
attempts to relieve the pruritus, often produces painful excoriations, 
which increase his misery. 



180 DISEASES ARISING FROM GENERAL CAUSES. 

Prurigo pudendalis is a most distressing affection, but happily, 
one of unfrequent occurrence. The disease is situated chiefly on the 
labia majora, and mucous membrane of the vulva, but sometimes 
extends upwards along the vagina. The pruritus is generally con- 
stant, and so violent as to induce an unceasing necessity for friction 
with hard substances, or scratching. The continuance of the itching 
produces inflammation and swelling of the parts affected, and induces 
symptoms approaching nymphomania. 

Diagnosis. — Prurigo is distinguished from other papular eruptions 
by the morbid alteration of the skin, and by the burning pruritus. 
These characters serve to render the diagnosis between prurigo and 
lichen very simple. The minute scabs which succeed the broken apices 
of the papulae of prurigo are very similar to those of lichen simplex 
and scabies. 

Prurigo cannot be confounded with scabies, when it is recollected 
tli at the signs of the latter are a ragged and undermined state of the 
epidermis, the presence of vesicles, and, above all, of the acarus scabiei. 
The pruritus of the two diseases is also different ; in prurigo it is 
burning and tingling, and occurs in paroxysms, while in scabies it is 
constant, and more supportable ; situation forms another ground of 
diagnosis. 

Causes. — Prurigo appears at all seasons of the year, and at all 
periods of life, being modified by its occurrence at certain ages. Thus, 
in children and adults, the first two varieties are most frequent, while 
in old persons and weakly children, prurigo senilis generally appears. 
It has been remarked that prurigo mitis is chiefly seen during the 
spring and summer months. The causes of prurigo are want of clean- 
liness, insufficient clothing, residence in unhealthy situations, amenor- 
rhea, dysmenorrhea, uterine irritation associated with pregnancy, &c. 
Prurigo formicans is occasionally induced by the presence of visceral 
disease. and mental affections of long continuance, improper and over- 
stimulating diet, stimulating drinks, deficient and improper food, &c. 
Prurigo senilis appears to depend upon debility of the system, a state 
which is popularly expressed by the term, impoverished blood. 

Prognosis. — Prurigo is often exceedingly obstinate, and resists 
every kind of treatment, and in old persons, by the continuance of 
irritating and unappeasable pruritus, may be destructive of life. In 
young and adult persons it is not attended with danger. 

Treatment. — The first point, and one of the most important in the 
treatment of prurigo, is the employment of baths, which should be 
used daily. The temperature of the baths should not be higher than 
seventy degrees, and they may consist of simple water with soap, the 
alkaline, or sulphur bath. When the daily use of the alkaline or sul- 
phur hath is found to irritate the skin, it should be alternated with the 
simple soap bath. The cold water bath and sea-bathing may also be 
found useful in restoring the tone of the nervous system and skin, and 
promoting recovery. 

With a view of exciting a new action in the diseased skin, ami 
modifying its morbid condition, stimulating applications, such as the 



LICHENOUS OR PAPULOUS ERUPTIONS. 181 

tincture of croton, either pure (page 127) or diluted with an equal part 
of spirit of rosemary, may be prescribed. Previously to the use of the 
croton,* the skin should be prepared by repeated frictions with a damp 
gponge dipped in fine oatmeal, and then washed; and after the decline 
of the eruption which the croton excites, the frictions with oatmeal 
should be continued. After a few applications of the croton in this 
way, the bichloride of mercury in almond emulsion, in the proportion 
of fifteen or twenty grains to the half pint, will often complete the 
cure. I have seen considerable benefit result from the use of the tinc- 
ture of iodine painted on the morbid surface. Another local remedy 
frequently of service in allaying the itching of prurigo senilis, is gly- 
cerine, applied by means of a sponge. 

The applications best suited for the temporary relief of pruritus are 
vinegar, lemon-juice, weak solution of bichloride of mercury, tincture 
and watery solution of opium, creasote ointment and lotion, tar oint- 
ment, and especially that of the juniper tar, ointment of opium with 
camphor, the diluted nitrate of mercury ointment, ointment of lime, 
lotion of hydrocyanic acid, acetate of ammonia, muriate of ammonia, 
sulphuret of potash, chlorate of soda, &c. It is always necessary, as 
well as desirable, to have a number of anti-pruritic remedies at hand ; for 
it frequently happens that one may be successful while all the rest fail, 
and it is constantly found that a remedy which may be perfectly ef- 
fectual for this purpose in one case may be utterly useless in the next; 
I therefore subjoin several formulse recommended by French dermato- 
logists, and quoted by M. Gibert. One of these is an ointment con- 
sisting of hydrate of lime, 5\j ; subcarbonate of soda, laudanum, aa 5ss ; 
and lard, §j. An anti-pruriginous ointment recommended by Alibert 
is as follows : Laudanum, sublimed sulphur, aa 5ss ; oxide of zinc, 5j ; 
oil of almonds, 5j ; lard, §iij. Biett employed successfully, for an 
obstinate prurigo of the hands : Cinnabar, laudanum, aa 5\j ; sublimed 
sulphur, §ss ; lard, §v. And for local prurigo, the following was 
found of service : Muriate of ammonia, 5j ; powder of white hellebore, 
5ss ; lard, ^iij. 

The general treatment of prurigo must consist in the avoidance 
of stimulating food and drinks, and the use of laxative medicines, 
diuretics, diaphoretics, alkalies combined with bitter infusions, acid 
tonics, &c. Sulphur with cream of tartar, in moderate doses night 
and morning, for two or three weeks, is sometimes found useful, par- 
ticularly in the prurigo mitis of children. If the patient have a full 
pulse, and be plethoric, the loss of a quantity of blood proportioned 
to his strength is requisite, especially in cases of prurigo formicans. 
Indeed, I have seen bleeding in such cases act like a charm in allaying 
the unappeasable torture from which the patient was suffering. In 
prurigo senilis, a generous and nutritious diet is indicated, with oc- 
casional luxative and tonic medicines. When the disease resists the 
influence of other means, Donovan's solution, or the liquor arsenicalis, 
may be exhibited without hesitation ; of the former, ten to twenty 
minims three times a day; of the latter, three to five ; with meals. It 
is necessary, in directing the use of these solutions, to advise the com- 
mon precaution of avoiding acids, fruits, and vegetables, and the 



182 DISEASES ARISING FROM GENERAL CAUSES. 

omission of the drops -whenever any pain, giddiness, or uneasy sen- 
sations in the head, nausea, sickness, or pinchings of the stomach, are 
experienced. They may be resumed after a rest of a day or two, or 
as soon as the symptoms have subsided, and if necessary be continued 
in a diminished dose. 

Prurigo podieis and prurigo scroti must be treated on the general 
principles stated above ; in most cases constitutional treatment is re- 
quired. The local means for relieving the pruritus are especially 
needed in prurigo podieis and prurigo scroti; and, in the former, ab- 
straction of blood from the verge of the anus, by means of leeches, 
might possibly be useful. Additional local applications are, cold poul- 
tices or compresses, ice, cold hip-baths, opium suppositories, cold cream, 
poultices saturated with liquor plumbi, aeetate of lead ointment, the 
dilute nitrate of mercury ointment, the yellow and black wash, chlorate 
of soda lotion, &c. 

In prurigo pudenda lis the local remedies recommended above will 
be found useful, and their use must be aided by general means, and 
by depletion, by leeches, from the vulva. The juniper tar ointment is 
particularly useful in prurigo of the pudendal region. 



CHAPTER VII. 

DISEASES ARISING FROM GENERAL CAUSES. 
ECZEMATOUS OR VESICULAR ERUPTIONS. 

The special character of the eruptions considered under this head, 
is the effusion on the surface of the derma, and beneath the epidermis, 
of a colorless and limpid or ichorous fluid which raises the epidermis 
into small vesicles. In the eruption called sudamina no other cha- 
racters are present ; but in eczema, which is the typical form of the 
affection, there is more or less vascular congestion of the skin, namely, 
erythema ; more or less oedematous swelling ; and more or less of a 
lichenous eruption resulting from congestion of the vascular parietes 
of the cutaneous follicles. In those regions of the body where the 
epidermis is thin, it is easily lifted from its bed by the effusion beneath 
ir. and the vesicles are distinct and well defined; but where the epi- 
dermis is thick, as on the fingers and hands, as also on the feet, the 
effused ichor being resisted in its vertical pressure, the vesicles are not 
so distinct, and the fluid spreading horizontally, the epidermis becomes 
separated from the derma, to a greater or less extent; and on the de- 
cline of the eruption is thrown off in large flakes. 

Willan's definition of vesicula is, "a small orbicular elevation of the 
cuticle, containing lymph, which is sometimes clear and colorless, but 
often opaque, and whitish or pearl colored. It is succeeded either by 
scurf or by a laminated scab." Vesicles are rarely seen in the precise 



ECZEMATOUS OR VESICULAR ERUPTIONS. 183 

and definite form here described, excepting in situations favorable for 
their development, as on the back of the hand, and at the commence- 
ment of the eruption. At this early period they may be seen like trans- 
parent granules on the skin, some discrete, and others confluent ; later 
in the progress of the complaint the epidermis may have been rubbed 
off, and then the ichorous secretion becomes the prominent feature of 
the disease. At the first moment of effusion the ichor or lymph is 
always transparent, and mostly colorless, or slightly tinged with the 
coloring principle of the bile ; very soon it becomes whitish and 
opaque, and the vesicles have the appearance of minute pearls. The 
exact seat of the vesicles is the same as that of the papules of lichen,, 
namely, the apertures of the follicles of the skin, where they may be 
developed completely round the opening, or merely on its lip. 

In his Order Vesicuke, Willan assembled seven genera of eruptions, 
namely, varicella, vaccinia, herpes, rupia, miliaria, eczema, and aphtha. 
Of these seven I have retained only two, namely, eczema, as the type 
of the eruption, and miliaria. Of the remaining five, varicella and 
vaccinia are forms of variola, and are classed with that disease. Herpes 
I have taken as the type of a group of large, vesicle^ gradually 
expanding into the bullae of pemphigus. Rupia I have transferred to 
its proper place among the syphilitic eruptions; and aphtha, although 
a simple vesicular eruption, is an affection of the mucous membrane, 
and not of the skin. 

In the present group of cutaneous affections, the eczematous group, 
I have thought it right to restore to its proper place, that term derived 
from the Hebrew, tsorat, namely, psoriasis, which, as Mason Good 
observes, "having lost its primitive and restricted signification, seems to 
have wandered in search of a meaning, and had at different times, and by 
different persons, various meanings attributed to it ; being sometimes 
used to express scaly eruptions generally, sometimes the scales of 
leprosy; but at last, and with a pretty common consent, the far 
slighter efflorescence of scaly tetters or scalls, denominated in the 
Levitical code saphat ; and by the Latins scabies, or impetigo sicca." 1 
Psoriasis, in its proper acceptation, signifies a scaliness of the skin, 
resulting from chronic erythema, attended with thickening of the 
tissues of the derma, and more or less chapping of the inflamed part; 
in a word, chronic eczema, when eczema, has produced a thickened and 
chapped state of the skin, and ceasing to pour out an ichorous secre- 
tion, throws off from the inflamed surface a successive crop of scales; 
or chronic lichen agrins, when lichen has left a similar condition of the 
skin, the papules of the original eruption being obliterated in the 
general thickening of the chronically inflamed part. In brief, psoriasis 
is to eczema and lichen agrius what pityriasis is to erythema. 

It will be seen by these observations that I might have introduced 

1 Riolanua terms Eczema scabies humida; and defines the other division nf scabies, 
namely, scabies ticca, as being rough and pimply like goose-skin, in which definition we 
recognize our present lichen. And scabies sicca, according ;is it produces small and fur- 
furaceous scales, or larger ones like fish scales, he denorai nates psora porrigo and psora lepra. 
Psora porrigo, therefore, corresponds with the pityriasis of modern nomenclature, and psora 
lepra with lepra vulgaris. 



184 DISEASES ARISING FROM GENERAL CAUSES. 

psoriasis into the group of lichenous eruptions following lichen 
agrius ; but I have preferred to attach it to eczema, and the more so, 
because lichen agrius may be regarded as holding a transition-place 
between lichen and eczema, as being in fact a lichen passing into the 
stage of eczema, or assuming the characters of eczema, of being 
indeed -a lichen eczematosus. 

Under the head of Lepra will be shown the differences between that 
disease and psoriasis, two affections commonly grouped together at the 
present day, from the existence of scales in both ; but essentially 
distinct in the nature of their respective scales, and equally distinct 
in their origin and phenomena. 

ECZEMA. 

Syn. Ecphlysis eczema, Mason Good. Humid tetter, or scall. Dartre 
squameuse humide, Alibert. Heat eruption. 
Eczema 1 (Plate IX.) is a non-contagious affection of the skin, 
characterized by the eruption of minute vesicles in great numbers, 
and frequently confluent, upon a surface of irregular form, and 
usually of considerable extent. The vesicles are so closely aggregated 
in some situations, as to give rise to one continuous vesicle of great 
breadth. These larger vesicles, when laid open, appear to be cellular 
in their structure ; the cellular disposition obviously depending on 
the juxtaposition of the numerous small vesicles of which they are 
composed. The vesicles of eczema terminate by absorption of the 
fluid which they contain, or by rupture and moist excoriations 
succeeded by thin crusts, and by furfuraceous desquamation. The 
eruption is generally successive, and variable in duration ; it some- 
times extends to the mucous membrane, and is often developed on the 
scalp, and hair-bearing parts of the body. 

The varieties of eczema are divisible into two groups, acute and 
chronic. In the former are arranged four principal varieties, and in 
the latter, one only. Besides these, several local forms of the disease, 
either from their severity, or from certain peculiarities which they pre- 
sent, deserve separate consideration, and may be assembled in a third 
group, the members of that group being susceptible of assuming, as 
circumstances may determine, either the acute or the chronic type. 
The varieties of eczema, therefore, are, — 
1. Acute. 
Eczema simplex, Eczema impetiginodes, 

" rubrum, " infantile. 

2. Chronic. 
Eczema chronicum, vel psoriasis. 
3. Local forms. 
Eczema capitis, Eczema pudendi, 

" faciei, " articulorum, 

" aurium, " manuum et pedum. 

" mammillarum, 

1 Der sK^eTy, effervere, to boil out. 



ECZBMATOUS OR VESICULAR ERUPTIONS. 185 

ECZEMA SIMPLEX. 

Syn. Humid tetter. Eczema solare, Wilian. 

In this, the most simple form of eczema 1 (Plate IX., I i) the 
vesicles, about the size of the head of a small pin, exceedingly 
numerous, and clustered into confluent patches of various extent, are 
accompanied by only a slight degree of redness and inflammation of 
the skin. 

The eruption makes its appearance suddenly, without premonitory 
symptoms, and the vesicles are distended with a transparent lymph, 
which gradually becomes opaline, and afterwards milky. The fluid 
is then by degrees absorbed, and the epidermis shrivels into a thin 
pellicle, which is thrown off by desquamation. When, however, the 
vesicles are broken, as frequently occurs, the scale which follows is 
thicker and more adherent, and remains attached to the surface for a 
longer period. The affection is generally prolonged by successive 
eruptions for two or three, and sometimes for a greater number of 
weeks, but is so slight as to leave behind it no trace of the previous 
existence of morbid action. It is accompanied by itching, which is 
sometimes considerable and troublesome, but presents no constitutional 
symptoms. Kayer remarks that the vesicles " usually correspond 
with the minute projections whence the hairs issue, and which may 
be very distinctly seen by examining the insides of the arms and 
thighs with attention." 

Eczema is sometimes general, but more frequently local, and may 
occur on any part of the body. Rayer alludes to a variety of eczema 
simplex described by Dr. Levain. This variety, which is purely 
accidental, and appertains rather to eczema rubrum than eczema sim- 
plex, is " distinguished by clustered patches of vesicles, the dimen- 
sions of which vary from those of a sovereign to those of a two- 
sovereign piece." "The clusters are scattered over the skin, which 
only appears red in the places affected. On the red patches, covered 
with vesicles, the cuticle may sometimes be raised and removed in a 
single piece." 

ECZEMA RUBRUM. 

Syn. Humid tetter. Running scall. Dartre vive. Dartre squameuse 
humide, Alibert. Dartre erysipelateuse. Herpes squamosus madi- 
dans. 

Eczema rubrum, or inflammatory eczema (Plate IX., K k), is dis- 
tinguished from the preceding variety by the development of the 
vesicles upon a surface which is tense, swollen, and of a vivid red 
color. The eruption appears, in the first instance, in the form of mi- 
nute white points, dispersed in great numbers over the inflamed sur- 
face. These speedily increase in size, and become small, transparent 
vesicles, filled with a viscous, colorless lymph, and surrounded by an 

1 "Portraits of Diseases of the Skin," Plate III., X represents eczema simplex and 
eczema rubrum on the arm and hand. 



186 DISEASES ARISING F R M GENERAL CAUSES. 

areola of deeper redness. At other times, the skin being red and 
swollen, the pores are elevated into pimples like those of lichen. The 
slightest friction, or the removal of a dressing which has adhered to 
the pimples, brings off the loosened cuticle which covers them ; and 
then, in lieu of pimples, we have small circular excoriations, about 
one line in diameter, and more vividly red than the rest of the skin. 
These little circular excoriations are dispersed irregularly over the 
inflamed surface, some being isolated, others confluent, while here and 
there they constitute a patch of larger size; they are moist with an 
ichorous discharge which they pour out, often in large quantity, and 
resemble so many little springs issuing on the inflamed surface. When 
the disease terminates favorably, the redness subsides at the end of a 
few days or a week, the fluid contained within the vesicles is absorbed, 
and their epidermal parietes shrivel and dry up, forming thin scales, 
which are thrown off by desquamation, leaving a redness of the skin, 
which continues for a considerable time. 

When the affection is more severe, the inflammation augments, and 
the vesicles become confluent. Their contents, at first transparent, 
become turbid and milky; they burst almost as soon as formed, and 
leave behind them inflamed and excoriated surfaces, which pour out 
an abundant secretion. The ichor from the inflamed surfaces is pro- 
fuse and irritating, and serves to increase the extent of the excoria- 
tions. 1 The exposed derma is of a bright crimson color, and is covered 
here and there with flakes of a whitish membranous film. Some of 
these crimson excoriations are bordered by an abrupt margin of thick 
and softened epidermis. When the discharge diminishes in quantity, 
it concretes into the form of softish lamellae, which harden by exposure 
to the atmosphere, and constitute scabs of various extent and thick- 
ness. The more severe degrees of eczema rubrum endure for several 
weeks, and are apt to assume the chronic form. 

Eczema mercuriale. — A form of eczema rubrum, only differing 
from that now described in its supposed exciting cause, has been dis- 
tinguished by the name of eczema mercuriale, and has received the 
various synonyms of Hydrargyria ; Erythema mercuriale; Erythema 
vesiculare; Erythema ichorosum, Marcet; and Mercurial lepra, Mori- 
arty. Dr. Alley describes three varieties, or rather degrees, of this 
rare affection — namely, hydrargyria mitis, febrilis, and maligna. 

Eczema mercuriale is characterized by a red efflorescence occurring 
in patches of variable size, and surmounted by minute transparent 
vesicles. In the mild form of the affection the vesicles are very small, 
but in the more severe degrees they are larger, and their transparent 
contents opaque and purulent. In some instances, where febrile syrnp- 
toms are present, the efflorescence occupies a large extent of surface, 
sometimes the entire body, and assumes the appearance of roseola ; at 
a later period the blotches coalesce, and form patches of larger size. 
The usual seat of the eruption is the trunk, or the thin skin of the 
pudendal region ; sometimes it appears first on the backs of the hands, 

1 A patient from the west of England, who consulted me lately, in reference to tliis 
ichorous secretion, made use of the very expressive term "anguish water.'' 



ECZEMATOUS OR VESICULAR ERUPTIONS. 187 

and more rarely on the face. The eruption is preceded by heat and 
smarting of the skin, and its progress is marked by excessive heat, 
smarting, and pruritus. When the vesicles are minute, they dry up 
without giving rise to secondary inconvenience : but when they occur 
in folds of the skin, or are larger in size, they are usually broken, and 
the abraded derma pours out an acrid and offensive 1 ichor in consider- 
able quantity. When the eruption declines, as usually happens about 
the tenth or twelfth day in the mild form of the disease, and at a varia- 
ble period later in the severe forms, the epidermis is thrown off by 
repeated desquamation, leaving the skin of a deeply red color. Some- 
times at the close of the eruption the disease concentrates itself on a 
particular spot, and remains obstinately fixed for weeks or months. 

Mercurial eczema, in its mildest form, may appear without consti- 
tutional symptoms, or with trifling gastro-intestinal disturbance and 
feverishness. But in a more severe degree — that, for instance, named 
febrilis by Dr. Alley — the attack is marked by rigors, nausea, pains in 
the head, diminished secretions, and other symptoms of constitutional 
disturbance. The fauces are more or less inflamed, and the congestion 
of the mucous membrane often extends to the bronchial tubes. In 
the most violent form of the affection, namely, in that produced by a 
continuance in the use of mercury after the eruption has appeared, 
the hydrargyria maligna of Dr. Alley, the face is enormously swollen, 
the eyelids closed, the throat tumefied and painful, the color of the 
efflorescence of a deep purple color, and all the symptoms aggravated. 
The epidermal exfoliation continues for a greater length of time, it is 
thrown off in large flakes, and the nails are sometimes cast with the 
epidermis. Persons who have once suffered from eczema mercuriale 
are subject to subsequent attacks. 

The mercurial eruption is sometimes the consequence of a long- 
continued use of mercury, but occasionally would seem to depend on 
a peculiar idiosyncrasy of the individual, unless we suppose the eyes 
of the observers to have become so obscured by a favorite hypothesis, 
as to see nothing but hydrargyria in every inflammatory eczema, 
developed after taking a dose of medicine containing a particle of 
mercury. This idea is naturally suggested when we read of eczema 
mercuriale following the exhibition of a single blue pill ; but I am 
bound to admit, that in certain constitutions the influence of mercury 
is poisonous even in the smallest quantity. I once saw a man salivated 
by the metallic alloy used for stopping his tooth ; and I have at pre- 
sent under my care a lady who has several times had a very troublesome 
attack of lichenous erythema following the administration of a small 
dose of mercury. She is so sensitive of this metal that she has more 
than once detected it in her medicine when it had been inadvertently 
prescribed ; and on a late occasion, having received on her hands and 
arms the gastric fluids of her child, who had taken a dose of gray 
powder, in a few hours afterwards she felt a return of the old irrita- 
tion of the skin. More commonly, mercurial inunction, or a mercu- 
rial atmosphere, has preceded the eczematous eruption. Dr. Alley 

1 Spens compares it to putrid fish. 



188 DISEASES ARISING FROM GENERAL CAUSES. 

conceives that in his case the effect of the mercurial ointment may 
have been heightened by its admixture with camphor, the formula 
consisting of two scruples of the latter to an ounce of the unguent. 
Dr. Moriarty 1 assigns opium as a cause of this eruption. Indeed, the 
susceptibility of the skin after an attack is so great, that in Hewson 
Bigger's case it recurred several times under the use of opium. In 
Dr. Crawford's case, 2 the eruption was reproduced by one grain of 
opium. 4 Cold, also, has had the effect of re-exciting it. 

The treatment of eczema mercuriale consists in the removal of the 
cause, and the pursuance of the general plan laid down for the manage- 
ment of eczema rubrum. Dr. Crawford found a liniment of oil and 
lime-water the best local application. Internally he gave tonics. Dr. 
Marcet's 3 case, which followed an attack of gonorrhoea, was treated 
with the warm bath, poultices moistened with liquor plumbi, and dia- 
phoretic laxatives. 4 

ECZEMA IMPETIGINODES. 

Eczema impetiginodes (Plate IX., l l) may either be a severe degree 
of eczema rubrum — that is, an eczema rubrum aggravated by irritating 
causes to the production of the small psydracious pustules of impetigo, 
or a copious semipurulent secretion ; or it may be an eczema rubrum 
developed in a person possessing the pyogenic diathesis, as commonly 
happens in weakly lymphatic children and women. Devergie remarks, 
that eczema takes on the impetiginous character in the proportion of 
thirty-five per cent. 

In eczema impetiginodes the skin is highly inflamed and swollen, 
and the vesicles, in many places aggregated into confluent clusters, 
often communicate with each other, and form a continuous vesicle of 
some extent. The contents of the vesicles, at first limpid, soon become 
turbid and puriform, and are effused on the surface by the rupture of 
the epidermis, and the purulent secretion concrete into yellowish, 
lamellated crusts, often of considerable extent. When the crusts are 
rubbed off*, or removed, the exposed surface of the derma presents a 
vivid crimson color, partly concealed here and there by films of whitish 
lymph, and secreting an abundant ichorous fluid, having a reddish 
tinge. This secretion hardens, if the inflamed surface be exposed to 
the influence of the atmosphere, into a thin, dark-colored scab, which 
remains, unless disturbed by accident or design, until the excoriated 
surface is healed. 

The eruption of eczema impetiginodes, as of the milder forms of the 
disease, is successive; fresh crops of pustular vesicles are produced as 
tin- fust decline, and the disease is prolonged for two, three, or more 
weeks, often lapsing into the chronic form of eczema. 

Eczema impetiginodes is for the most part local in its attack, con- 
fining itself to a single region of the body, and that of limited extent. 
The forearms and hands are the frequent seat of the disease, and the 

1 Edinburgh Medical and Surgical Journal, vol. xvi. p. 37. 2 Idem. 

3 Medico-Chirurgical Transactions, vol. ii. 

4 The Edinburgh Medical and Surgical Journal contains other cases by Dr. Spens, 
vol. i. ; Dr. MacMullen, vol. ii. ; Dr. Rutter, vol. v. ; and Dr. Ramsey, vol. vii. 



ECZEMATOUS OR VESICULAR ERUPTIONS. 189 

face is not uncommonly affected. In these cases there are no special 
constitutional symptoms. But when the eruption is general, or when 
children are the subjects of the partial affection in any degree of 
severity, the ordinary constitutional symptoms accompanying inflam- 
mation are developed, viz., quick circulation, excited nervous system, 
disordered digestive system, and diminished secretions. The local 
symptoms are burning and distressing heat, and excessive smarting 
and throbbing, augmented by the warmth of bed, and destructive of 
sleep. 

ECZEMA INFANTILE. 

Syn. Crusta lactea. Tinea lactea. Porrigo larvalis. Tinea mucosa ; 
Tinea granulata ; Alibert. Milchgrind, Milchschorf ; Germ. Psori- 
asis infantilis. 

Infants at the breast and young children are peculiarly subject to 
eczema, and in them it is apt to assume the severest form presented 
by cutaneous disease. In young infants it commences at the end of 
the first month or six weeks, and, unless submitted to proper treat- 
ment, may continue for months and years ; in fact, lay the foundation 
of a cutaneous disease which may be prolonged in a chronic form 
until manhood, or may hang about the patient for the remainder of 
his days. 

Eczema infantile, like eczema adultorum, originates in mal-assimi- 
lation, and, with good reason, is commonly ascribed to a faulty 
secretion of milk on the part of the mother; but when once estab- 
lished, is not remedied, as might be expected, by the withdrawal of 
the cause and the substitution of a different and less faulty food. 
Unsuccessful attempts to cure the disease, probably, carry the child 
on to the period of cutting the teeth; then the continuance of the 
disease is attributed to dentition, this time without so good reason, 
and hopes are raised that when the milk teeth are perfected the 
disease will subside. The milk teeth are all cut, but still the eczema 
lingers, and then a new light of prophecy beams upon the little 
patient; when puberty arrives, then certainly the disease will go; but 
puberty possesses as little of the physician's art as change of food, or 
completed primary dentition ; and so the malady becomes perpetuated. 
I have seen this picture in life so frequently that I could not refrain 
from sketching it. 

It is remarkable how trivial an exciting cause may become the 
origin of this distressing malady. A lady, six weeks after her confine- 
ment, travelled by the railroad from London to the sea-coast, carrying 
with her her infant. She was chilled by the journey, Avas feverish 
during the night ; her infant was feverish the following day, and 
threw out an eruption of eczema, which brought the child to me some 
months afterwards. This day a neighbor brought me her infant 
covered with eczema from head to foot; the child was a few months 
old ; in her confinement the mother lost her husband under painful 
circumstances; the distress caused by this affliction was transmitted 
to the offspring as an eczema rubrum. How small the cause of mal- 



190 DISEASES ARISING FROM GENERAL CAUSES. 

assimilation in these cases, which may be taken as the type of the 
whole family; how easily is the assimilative function of infants 
disturbed; how difficult often to restore ! 

When cutaneous eruption attacks an infant under these circum- 
stances, it revels in all the t} T pical and modified forms of cutaneous 
disease. At the same moment, and on the same child, may be seen 
erythema, lichen, strophulus, eczema, impetigo, pityriasis, and psori- 
asis, and an observant nurse seems to take a special delight in pointing 
out the various diseases which pervade the flesh of the poor little 
sufferer. In certain parts of the body erythema is apt to prevail; but 
a broken or cracked state of the skin, with however small a degree of 
ichorous oozing, must determine the case to be an eczema. On the 
back lichen is apt to predominate; on the head, in the bends of the 
joints, and on the pudendum, eczema; on the cheeks and ears, eczema 
impetiginodes; all on the same skin and in gross defiance of the 
orders, genera, and species of the Plenckio-Willanean method of 
classification. 

The predominance of one or other of the typical forms of cutaneous 
eruption is determined by the condition and temperament of the 
infant. The child may present every shade of variation of appearance 
from a state difficult to distinguish from complete health to one in 
which the little thing is attenuated and shrivelled up, and looks like 
a little old man. In the former extreme, however ruddy and full the 
child may seem, there is evidence of an existing weakness in the soft- 
ness of its muscles ; but, w T ith that exception, no trace of disorder of 
constitutional health can be discovered. Next to softness of muscles 
comes pallor in a slight degree; then an increasing whiteness of the 
eye, attributable to progressing anemia ; then follows emaciation ; the 
skin shows signs of wrinkles, becomes dry and discolored, and ulti- 
mately sordid. With these, the outward signs of the disease, of 
mal-assimilation in fact, there is rarely any disturbance, or but little, 
of the digestive organs; the child takes its food well, and is not 
paiticularly restless or fretful. Sometimes the motions are green; 
sometimes mingled with an excess of mucus, and sometimes white 
from suspended biliary secretion; but there is nothing beyond the 
commonest gastro-intestinal derangement, and that in a very insigni- 
ficant degree. 

The eruption usually commences as a patch or blotch of slightly 
raised pimples ; the patch is itchy, is rubbed, increases in size, becomes 
more inflamed, the cuticle is raised in more or less defined vesicles, 
which are usually broken by friction, the surface becomes excoriated, 
somewhat swollen, and pours out an ichorous secretion, varying from 
a mere oozing to an excess that wets through everything that is applied 
to it. With the increase of irritation, consequent on the excessive 
secretion and the congestion which gives rise to it, the patch spreads; 
where the eruption commenced by several blotches, they probably 
run into one; t he ichorous discharge also increases the local disease, 
by irritating the parts over which it flows. The case up to this time 
is one of inflammatory eczema, or eczema rubrum. The state of eczema 
simplex has hardly existed, and is only to be seen occasionally; but 



BCZEMATOUS OR VESICULAR ERUPTIONS. 191 

the disease still runs on, its violence increases, and the morbid secre- 
tion, from being a transparent and colorless ichor, like water in 
appearance, becomes slightly opaque (tinea mucosa), milky, then 
yellowish and semipurulent, and the case is transformed into eczema 
impetiginodesj or the discharge may take on a still more decidedly 
purulent character, while small pustules are developed on the red and 
tumefied skin around the patch, and then the case is one of impetigo. 
Thus the plus or minus of these pathological conditions, irrespective 
of the cause or essential nature of the disease ; in other words, the 
disease being the same, it may, according to the temperament or 
constitution of the child, be an erythema verging upon eczema; an 
eczema rubrum ; an eczema verging on impetigo or eczema impeti- 
'ginodes ; or, the pustular element being in excess, it may be an 
impetigo. Again, as I have before said, whatever the predominating 
character may be, whether erythema, lichen, eczema, or impetigo, 
there will always be present in a greater or less degree some, or the 
whole of the other forms sprinkled over the body ; a simple erythema 
here, an erythema with strophulus or lichen there, a few scattered 
vesicles of eczema in a third place ; or a few congregated psydracious 
pustules of impetigo in a fourth. 

In this description of the general characters of eczema infantile, I 
suppose the eruption to be comparatively undisturbed; but that is 
rarely the case, the great heat, the prickling, the tingling, the intense 
itching which accompany the disease, render abstinence from rubbing 
and scratching impossible ; hence these have to be added to the causes 
of aggravation of the local disorder. Again, the burning heat of the 
skin on the one hand, and exposure to the atmosphere on the other, 
tend to desiccate the surface very rapidly, the contents of the vesicles 
in the simplest form of the affection dry up into a thin, transparent, 
amber-colored crust; in eczema rubrum, with a more copious dis- 
charge, the crust is less transparent and thicker ; and in eczema impe- 
• tiginodes it is still further increased in thickness, is lighter both in 
color and texture, and uneven in surface ; while in impetigo, from the 
desiccated matter being pus, it is thickest of all, and has the appear- 
ance of dried honey; this circumstance has given the name of meli- 
tagra to the latter disease. As may be supposed, the crust presents 
considerable variety of appearance, according to the prevalence of 
accidental circumstances in a greater or less degree, such as accumula- 
tion of secretion, amount of desiccation, &c. Not unfrcquently, as a 
consequence of pressure or friction, blood is mingled with the dis- 
charges, and the crusts become colored of various hues from a lightish 
brown to positive black. Again, a variety of color results from the 
age of the crust, that which has been longest formed being usually 
lighter than the rest; and another difference occurs when the original 
crust is broken, and a new discharge issues from between the several 
fragments. 

Sometimes this terrible disease attacks the whole body of the child, 
and the little thing has scarcely a patch of sound skin on its entire 
surface, being covered from head to foot with erythema, excoriations, 
and scabs of every variety of size and dimensions, and giving out an 



192 DISEASES ARISING FROM GENERAL CAUSES. 

offensive valerianic odor which has been compared to the urine of cats ; 
but more frequently it is limited to one or more regions of the body, 
the commonest seats of the eruption being the head and face, the 
front of the chest, the umbilicus, the pudendal region, and the 
flexures of the joints. On the head the eruption is complicated by the 
presence of hair, which entangles the discharges, and the crusts are 
apt to form, in consequence, of considerable thickness, sometimes in- 
cluding the entire scalp in a thick, rugged, yellowish, and discolored 
cap. At other times, when the discharge is less abundant, it dries up 
into a friable crust, which, broken into small fragments by scratching 
and rubbing, has been compared to particles of mortar dispersed 
among the hair, and has received the name of tinea granulata. Many 
of these particles of crust being pierced by the hairs, have the appear- 
ance of a string of rude beads. Later in the history of the eruption, 
and when it has become decidedly chronic, when erythema of the 
scalp with copious furfuraceous desquamation are the leading charac- 
ters of the disease, it has been termed tinea furfuracea; and later still, 
when, with a slighter degree of erythema, the epidermal exfoliation is 
mealy, the case is one of pityriasis capitis. 

When the ears are attacked they become much swollen, and give 
forth an excessive quantity of ichorous secretion, which may be seen 
distilling from the pores of the skin, and standing in drops on the in- 
flamed and excoriated surface. When the disease fixes on the face it 
is also attended with swelling, and often gives the child a bloated and 
frightful appearance, every feature being distorted ; and the deformity 
is increased by the production of a thick discolored scab, which forms 
a mask sometimes to the entire face. This huge, unnatural mask 
covering the child's face, suggested the term larvalis, given to one of 
his species of porrigoby Willan ; only that, instead of porrigo larvalis, 
it should have been eczema larvale, or impetigo larvalis. Again, from 
occurring at the milk period of life, this extraordinary crust, whether 
arising from the desiccated secretions of eczema rubrum, eczema impe- 
tiginodes, or impetigo proper, has received the name of milk-crust, or 
crusta lactea. 

The inflammation of the scalp and face is apt to produce, as one of 
its secondary effects, enlargement, and sometimes suppuration of the 
lymphatic glands. Thus we find the gland situated behind the ear, 
the occipital, the submental, and cervical lymphatic glands swollen 
and painful ; and not unfrequently, in a pyogenic diathesis, there are 
superficial abscesses in the neighborhood of these glands. 

The pudendal region, both in the male and female infant, is not un- 
commonly the seat of the eruption, being determined to this region 
partly by the heat and moisture resulting from its function, and partly 
by the thinness and delicacy of the skin. 

For the latter reason it is commonly met with in the flexures of the 
elbows and knees, and sometimes in the axillse. In the flexures of the 
joints the inflamed skin is apt to crack into fissures of considerable 
length and depth, and often to bleed; the blood mingling with the 
excessive ichorous secretion poured out by the denuded skin. 

The general character of eczema infantile is to form patches of con- 



ECZEMATOUS OR VESICULAR ERUPTIONS. 193 

siderable size, several inches square, and to attack, as I have already 
explained, a whole region at once, such as the head, face, &c. ; but in 
addition to this, and sometimes without these extensive patches, the 
eruption appears in rounded blotches from half an inch to two inches 
in diameter, sprinkled upon the skin in various parts, as upon the 
trunk, neck, arms, and legs. These patches are identical with the cir- 
cumscribed patches which are seen upon the skin in lichen agrius, 
and the eruption has more of the character of the latter disease than 
of eczema rubrum. The blotches are raised, thickened, papulated, 
excessively irritable, discharging but a small quantity of ichorous 
fluid, and covered, when desiccated, with thin, squamous, laminated 
crusts. 

Eczema infantile, when left to itself, has no natural tendency to re- 
solution or spontaneous cure; on the contrary, it merges, progressively 
into a chronic form, and undergoes that kind of modification which is 
common to cutaneous disease when passing from an acute to a chronic 
stage. By degrees the ichorous discharge diminishes, and the erup- 
tion retires to certain situations, where it continues to linger, some- 
times subsiding into a state of calm, and sometimes breaking out afresh 
like* a slumbering volcano. The situations on which it most commonly 
retreats, are the scalp, the eyelids, the ears, particularly the backs of 
the ears ; the integument around the mouth, the arm-pits, the groins, 
and the bends of the elbows, wrists, knees, and ankles. The parts of 
the skin over which it has passed are arid and parched ; and the foun- 
tains of moisture, the natural secretions from the skin, the perspira- 
tory and sebaceous secretions, are dried up. On the scalp the dried 
and parched skin, continually throwing off a furfuraceous desquama- 
tion, presents the common characters of pityriasis capitis. And not 
only is the skin left in a state of parched exhaustion, but the hair also 
is dried up, is scanty in quantity, and its growth is arrested. 

The dry, parched, hot, fevered state of the skin, which is the com- 
mon sequel of eczema infantile, is a sign of the disorganization and 
extreme disturbance of function which the skin has undergone. Even 
where there was no eruption, the cuticle is rugged and constantly 
thrown off as a mealy exfoliation; but where the eruption existed, as 
around the eyelids, upon the ears, around the mouth, and in the bends 
of the joints, the skin is more or less red, thickened, uneven, cracked, 
and chapped, and the ichorous secretion having ceased, it throws off 
perpetually scales of dried cuticle of various size, some being mealy, 
others furfuraceous, and others as large as the finger-nail. This, then, 
is a case of genuine psoriasis ; eczema infantile has therefore become, 
by the mere result of continuance, chronic eczema infantile ; or, in 
other words, psoriasis infantilis. 

This process of constant exfoliation is necessarily attended with 
pruritus, which is often very considerable; the inflamed part is then 
rubbed and scratched, and from time to time the ichorous secretion is 
reproduced. 

1 have noted that, in the early outbreak of the eruption, the only 
trace of deteriorated condition that may be present in the child is a 
feeling of softness of the muscles, and a slight degree of paleness of 

13 



194 DISEASES ARISING FROM GENERAL CAUSES. 

the skin and of the conjunctiva ; in fact, the discernment of these 
trivial but nevertheless significant signs is a matter of observation and 
tact. Later, however, in the progress of the disease, these signs be- 
come sufficiently obvious to attract the attention of the unobservant ; 
and later still, the poor little child is strangely altered from its normal 
state ; mal-assimilation, cacochymia, are traced in conspicuous lines on 
every part of the surface, in every feature. The limbs are thin, show- 
ing out the prominence of the joints ; the muscles are soft and flabby ; 
the skin is soft and pasty, or discolored and shrivelled ; there is an 
expression of care, anxiety, of thought*, upon the little face ; from the 
general emaciation of the body, the head looks larger than natural ; 
as I before observed, one is struck with the senile look of the child ; 
the mucous membrane of the conjunctiva and mouth is pale ; and, 
above all, is the strangely white anaemic eye, sometimes dull and list- 
loss, and sometimes bright and clear. The eye tells an eloquent tale 
of defective nutrition. 

I have remarked above that the symptoms of internal disorder are 
but trifling at the commencement of the disorder ; and far from being 
severe through its course ; they attract little of the attention either 
of the mother of the child or of the medical man. The great, the 
urgent symptom of the whole is the teasing, the intense, the violent 
itching ; sometimes the itching is constant, with frequent exacerba- 
tions ; sometimes there are intervals of repose, which are apt to be 
disturbed by any change of temperature, and then a violent attack of 
pruritus recommences ; but the crowning suffering of all occurs at 
night ; the child is often frantic with itching ; it scratches with all its 
force, digging its little nails into the flesh, while the blood and ichor 
run down in streams. At last, worn out with suffering and exhaus- 
tion, the child sleeps, probably to be awaked again several times in 
the night by a repetition of the same agony. This constant suffering 
naturally wears out the child's powers, and added to the mal-assimi- 
lation, brings about that state of atrophy which I have previously 
described. But it is nevertheless remarkable how little the strength 
and spirits of the child are affected by these separate paroxysms of 
suffering ; in the morning, after a night of distress, the little thing is 
fresh and lively, eager for its food, and ready for the battle of the day; 
while the nurse or mother is languid and powerless, from watching and 
anxiety. 

• Not unfrequently, in eczema infantile, the mucous membrane of 
the mouth and nose, of the air-tubes and lungs, and of the alimentary 
canal, participates in the disease, and is either affected simultaneously 
with the skin, or takes a vicarious part. The affection of the alimen- 
tary canal gives rise to diarrhoea and the production of mucus in 
huge quantities, and sometimes of coagulated lymph. The affection 
of the mucous membrane of the mouth and nose is shown by redness, 
sometimes aphthae and augmented secretion ; and the eczematous con- 
gestion of the mucous membrane of the air-tubes produces bronchitis 
in various degrees, accompanied with hoarseness, from thickening of 
the mucous lining of the larynx, and an excessive accumulation of 
phlegm throughout the lungs. This latter symptom is one which is 



ECZEMATOUS OR VESICULAR ERUPTIONS. 195 

calculated to give us some anxiety, and requires dexterous manage- 
ment ; but it is less severe than common bronchitis, and is often as 
sudden in getting well as in its attack. When the mucous membrane 
of the mouth and air-passages is affected, hoarseness is a conspicuous 
and striking feature of the complaint ; the hoarse cry is unmistakable, 
and is sometimes the first and only sign of the congestion of the 
mucous membrane. It is a sign as diagnostic of congestion of the 
respiratory mucous membrane, as is whiteness of the eye of general 
anaemia. 

In the treatment of eczema infantile, the three great principles 
which I have already laid down as the law of treatment of cutaneous 
disease, namely, elimination, restoration of power, and alleviation of 
local distress, are to be put in force, but with a change in their order. 
Elimination must always go first ; but in eczema infantile I would 
place alleviation of local distress second ; and restoration of power 
third. Thus the principles of treatment, the indications for treatment, 
being settled, let us consider the means. 

For elimination, the remedy is calomel or gray powder : I prefer the 
former ; one grain of calomel rubbed down with one grain of white 
sugar, or sugar of milk, is the dose for the youngest infant ; for a 
child a year old, a grain and a-half ; for a child two years old, two 
grains. Of course this dose is modified according to the apparent 
strength of the child in the first instance, and in accordance with the 
action of the medicine in the second; the object to be obtained being 
such a dose as will produce an efficient relief to the alimentary canal ; 
and moreover, such an amount of relief as shall act as a diversion to 
the morbid secreting action taking place in the skin ; in other words, 
to divert the morbid secretions of the skin into their more natural and 
proper channel, the alimentary canal. For this purpose calomel excels 
every other medicine ; from its small bulk it is convenient for exhibi- 
tion, merely requiring to be dropped into the child's mouth ; it stimu- 
lates the liver to an increased flow of bile ; and in children it always 
acts most kindly on the alimentary canal. Again, a free action of the 
alimentary canal being secured, all probability of repulsion of the erup- 
tion by the remedies required for the second indication is at an end ; 
and the mother's and nurse's alarms lest the disease should be driven 
in are set at rest. A free clearance of the stomach and bowels is 
therefore a primary, a necessary step at the very commencement of 
the treatment. After the first dose, the calomel may be repeated 
according to circumstances ; once a week, twice a week, every other 
night for a few times ; even every night for two or three nights, if 
absolutely necessary. In my own practice, I usually find once a week 
sufficient, and I am guided to the repetition of the dose by the state 
of the little patient. If there be any feverishness, fractiousness, 
irritability of temper, any increase of pruritus, inaction of the bowels, 
morbid secretion of the bowels, or threatened congestion of the mucous 
membrane of the air-tubes, then the calomel powder is to be adminis- 
tered at once, without hesitation, and without delay. The mother or 
nurse soon learns the moment for a powder, and whatever prejudices 
they may have to the name of calomel, they arc always ready to re- 



196 DISEASES ARISING FROM GENERAL CAUSES. 

sort to it after they have once seen its action in this disease. As I 
have already said, I have no objection to the mercury with chalk 
beyond the fact of its being more bulky and less agreeable to swallow, 
while it certainly possesses no recommendation which can render it 
superior to calomel. Sometimes I find one or two grains of nitrate of 
potash a useful addition to the calomel and sugar. 

Having disposed of the first indication, and cleared out of the sys- 
tem any acrid matters that might be rebellious and capable of exciting 
irritation or feverishness ; having, moreover, unloaded the bloodvessels 
of some of their watery and solvent elements by the same remedy ; 
we may now have recourse to our means of alleviating the local distress, 
in other words, of soothing and healing the eruption, subduing the 
pruritus, and arresting the morbid discharge. We can do all this by 
the benzoated ointment of oxide of zinc, rubbed down with spirits of 
wine in the proportion of a drachm of the latter to an ounce of the former. 
This ointment should be applied abundantly, and gently distributed 
upon the surface until every part of the eruption has a . complete 
coating ; the ointment should be applied morning and night, and if 
accidentally rubbed off, or used upon parts exposed to the air and 
friction, it may be repeated more frequently. When once applied, the 
ointment should be considered as a permanent dressing to the inflamed 
skin, and never removed until the skin is healed, unless special condi- 
tions arise which render such a process necessary. To secure undis- 
turbed possession to the ointment, a piece of linen rag, a sheet of 
cotton wool, or a piece of tissue paper, should be laid over it and 
maintained in position by any convenient method. Thus, when the 
eruption covers more or less of the entire body, I have a little shirt 
made of old linen, with sleeves for the arms and legs, and means of 
being fastened closety around the legs, and, if necessary, closed over 
the hands and feet. This little dress is to be worn constantly, night 
and day, and for a week together, if necessary ; it is intended as a 
mere envelope or dressing to the inflamed and irritated skin, and its 
saturation with ointment, which necessarily ensues, only contributes 
to its greater utility in that capacity. Where the eruption is chiefly 
confined to the arms or legs, linen sleeves, with or without cotton-wool, 
will be sufficient for the purpose. On the face no other covering than 
the ointment is necessary, but the latter should, therefore, be used 
the more largely ; and sometimes in this situation, small pieces of thin 
tissue paper, of convenient size and form, laid on the ointment, are very 
serviceable. 

When the oxide of zinc ointment is employed in the maimer now^ 
described, the formation of crusts on the eruption is prevented, in 
consequence of the exclusion of the atmosphere, and the consequent 
absence of desiccation. And when crusts are already formed, the 
object to be attained is, to soften the crusts by saturating them 
thoroughly with the ointment, and then, by gentle friction, to displace 
them, and substitute a thin stratum of the ointment in their place. 
When the eruption passes from the acute into the chronic state, and 
the process of exfoliation of the cuticle is active, gentle friction of 
the skin with the ointment is even more desirable than in the acute 



ECZEMATOUS OR VESICULAR ERUPTIONS. 197 

stage of the disease, and is, at the same time, very grateful to the 
little patient. On the scalp the ointment should be applied in the 
direction of the hair, to avoid matting, and as soon as the oozing of 
ichorous discharge has somewhat subsided, the hair should be gently 
brushed. I am rigorous in enforcing the non-disturbance of the 
ointment, but sometimes my aides carry their instructions beyond the 
proper point, and accumulate the ointment too thickly over a given 
part, retaining thereby the secretions, and interfering with the cure ; 
in this case, if the finger be pressed upon such an accumulated plate 
of the ointment, the morbid fluids will be seen to ooze up between 
its chinks or around its edges, and the source of evil is detected. 
When such an occurrence takes place, the whole of the ointment 
should be carefulty washed off the part with the yelk of egg, and 
after drying the skin, fresh ointment should be applied. This 
excessive accumulation of the ointment takes place the most fre- 
quently on the scalp, encouraged by the matting of the hair, a reason 
for keeping the hair brushed whenever the nature of the eruption 
permits. 

Another of my instructions is to avoid washing the inflamed skin ; 
it may be wiped with a soft napkin, to remove exudations or 
secretions, but washing is unnecessary, indeed injurious, as tending 
to irritate the skin and increase the pruritus and inflammation after- 
wards. While the washing lasts, and the irritated skin is softened 
by the water, the part is relieved and comforted ; but the drying 
which follows after more than avenges the temporary solace of the 
ablution. On the same principle, I never order or recommend lotions 
in this eruption. 

In cases of chronic eczema infantile, that is, in pityriasis capitis and 
psoriasis partium aliarum, the stimulant properties of the nitric oxide, 
and nitrate of mercury ointments may be brought into operation ; 
the former is specific for pityriasis capitis-, in the proportion of one 
part to three of lard ; and the latter, variously diluted from one part 
in eight to equal parts, may be used for the chronic eczema or 
psoriasis of other parts, particularly of the eyelids. But even in the 
chronic state of the disease, the bcnzoated zinc ointment will be 
found to be an invaluable and indispensable remedy. In the parched 
state of skin left by the chronic disease, glycerine may be found of 
use as an emollient, but when any inflammation exists, it generally 
proves irritant, as compared with the zinc ointment. 

We now come to the remaining indication in the treatment of eczema 
infantile, namely, restoration of power ; in other words, to correct mal- 
assimilation, and restore the blood to its normal and healthy condition. 
For this purpose, the great remedy is that admirable alterative-tonic, 
arsenic. It is remarkable how well infants of the earliest age bear 
this medicine, and how rapidly in them it exerts its tonic and bon- 
assimilative effects. As an effective, harmless tonic, arsenic stands 
alone, and without its peer in this vexatious disease; indeed, in eczema 
infantile, it is specific ; it cures rapidly, perfectly, unfailingly ; it would 
be difficult to say as much for any other medicine in relation to any 
other disease ; and I pronounce this culogium on arsenic after a large 



198 DISEASES ARISING FROM GENERAL CAUSES. 

experience. The preparation of arsenic which I select, is Fowler's 
solution, the dose two minims to an infant from a month to a year 
old, repeated three times in the day, with or directly after meals ; and 
as mal-assimilation is always attended with anaemia, in a greater or 
less degree, I conjoin with the two minims of Fowler's solution, fifteen 
of vinum ferri, my formula being as follows : 

R. — Yini ferri, 

Syrupi tolutani, aa 3;ss. 

Liquoris potasste arsenitis, TtJJxxxij. 
^M. Aquae anethi, 3J. 

The dose of this mixture is one drachm, with or directly after meals, 
three times a day. 

With these three remedies, namely, the calomel powder, the benzo- 
ated ointment of oxide of zinc, and the ferro-arsenical mixture, repre- 
senting, as they do, the three indications for treatment of eczema in- 
fantile, I regard the cure as certain and rapid, and failure impossible; 
and if success were not complete, I should seek for the cause, not in 
the remedies, but in the mode of administering them. So confident 
am I of success, that I have often undertaken the treatment of this 
disease without seeing the patient, and at hundreds of miles distance, 
being satisfied, for my only aid, with the vigilance of an intelligent 
mother or nurse. I have never known any evil effects, present or 
future, result from this treatment, but I never fail to give strict in- 
junctions, that if the medicine appear to disagree with the child, it should 
be given less frequently, say twice, instead of three times a day, or sus- 
pended instantly, if the child appear ill ; moreover, that in the event of 
such an occurrence, the calomel powder should be immediately resorted 
to. The period of continuance of the remedies must be left to the 
judgment of the medical man; the treatment sometimes occupies three 
weeks, and sometimes more. And if a recurrence of the eruption take 
place, the treatment must be recommenced, and conducted on the same 
principle, and with the like precautions. 

The diet of the child while under this treatment must be carefully 
inquired into ; it should be good, wholesome, and nutritious ; the lead- 
ing constitutional indication is to nourish properly ; and this idea 
should be carried out in the food as well as in the medicine. I find 
the juice of meat of great value in these cases, and it may be given 
either alone, as beef or mutton tea, or mixed with the other food. 

The consideration of diet and food brings me to an important die- 
tetic medicine which is of great value in this disease, when the latter 
is attended with emaciation, and in the chronic stage; in acute cases, 
it is less applicable : 1 mean the cod-liver oil. The child will often take 
the oil greedily in its natural state, and its good effects on nutrition 
are speedily made apparent; it may be given with safety to the 
youngest infant. In children somewhat older, and particularly in 
chronic cases, the cod-liver oil chocolate becomes a useful ingredient 
of diet ; and it is in these latter, more particularly, that the chocolate 
was found so successful in the hands of my brother among my poor 
patients, as already mentioned. When I have wished to avail myself 
of the excellent properties of the cod-liver oil in conjunction with 



ECZEMATOUS OR VESICULAR ERUPTIONS. 199 

arsenic, I have often found the following formula a convenient vehicle 
for its use : 

R- — Olei jecoris aselli, §ij. 

Vitelli ovi, j. 

Liquoris potassse arsenitis, TTJJIxiv. 

Syvupi simplicis. gij. 
M. Aquse fontanse, q.s. ad ^iv. 

A drachm a dose, three times a day, with or directly after meals. 
When eczema infantile is complicated with diarrhoea or congestion of 
the mucous membrane of the air-tubes or lungs, the arsenical remedy 
should be instantly suspended, the calomel powder immediately ad- 
ministered, and ordinary antiphlogistic remedies adopted ; magnesia 
and aromatic confection for diarrhoea ; and ipecacuanha for the bron- 
chitic or pulmonary congestion. Where the air-tubes are loaded with 
phlegm, an emetic is sometimes useful ; and a poultice to the chest and 
abdomen will be found to be a valuable adjuvant. 

In concluding my observations on eczema infantile and its treat- 
ment, I must repeat, that I know of no cases in the whole catalogue 
of the diseases of the human frame, in which the disease itself is more 
unpromising in appearance and distressing in its effects, and at the 
same time more amenable and tractable under the treatment now laid 
down, than this disease. 



ECZEMA CHRONICUM — VEL PSORIASIS. 

Whenever, from the continuance of any of the preceding forms of 
eczema for a lengthened period, either as a result of the severity of 
the original disease, or of mismanagement in its treatment, the sur- 
rounding skin is irritated by the ichorous discharge secreted by the 
excoriations, the deeper textures of the integument become more or 
less involved in the morbid action. The skin is inflamed and swollen, 
the subcutaneous cellular tissue becomes dense and infiltrated, new 
excoriations, with deep and extensive chaps and fissures, are produced, 
and more or less ichorous secretion is poured out by the diseased 
structure. The chronic form of eczema is most frequently met with 
in the flexures of joints, more rarely it extends over a considerable 
surface, and occasionally involves an entire limb. It is obstinate and 
troublesome under treatment, and frequently endures for months or 
even years. 

Sometimes the secretion diminishes in quantity, and concretes into 
thin, yellowish, lamellatcd scabs,* which fall off from time to time, and 
are replaced by successive deposits of thinner scabs. The surface 
upon which they rest becomes less red and hot, and the diseased skin 
appears to be gradually progressing towards cure, when suddenly the 
redness and tumefaction return, and a fresh discharge is produced. 
In this manner, fresh and fresh outbreaks occurring at intervals, the 
morbid action is kept up for months, and often for years. 

In another variety of psoriasis the eruption forms a circumscribed 
patch, which is callous and dense, sometimes thin and dry like parch- 
ment, sometimes thick like buckskin, and sometimes horny and warty 
in character from hypertrophy of the papillae of the skin, and the 



200 DISEASES ARISING FROM GENERAL CAUSES. 

consequent production of the cuticle in sheaths, which are vertical to 
the surface. All discharge has long since ceased on these patches, 
and in their pathological nature they have degenerated into dry, 
thickened, callous erythematous patches, generally smooth on their 
surface, or only roughened with epidermic exfoliations, but susceptible 
at any time of becoming inflamed, and chapped, and pouring out an 
ichorous exudation. It is these patches that realize the true idea of 
psoriasis more fully than any other form of eruption. 

Chronic eczema is attended with severe itching, which is only 
relieved when a free ichorous discharge is emitted, and which com- 
monly follows the act of rubbing and scratching, or when the scratch- 
ing is succeeded by the escape of a little blood. Sometimes the 
scratching exasperates the irritation, and the whole nervous system is 
thrown into a state of great excitement. Moreover, in certain situa- 
tions, the pruritus is sometimes unbearable, and almost maddening, 
exciting the wildest paroxysms; as, for instance, when it occurs in 
the vulva, upon the scrotum, or around the anus. 

Occasionally the irritation of chronic eczema takes on the character 
of cutaneous neuralgia, and then the sufferings of the patient are very 
severe. I once saw a distressing case of this kind, where the chief 
seat of the eczema tous disorder, and of the neuralgia, was the axillae. 
As may be inferred, the constitution of the patient in these cases is 
highly nervous; the abnormal nervous susceptibility sometimes result- 
ing from idiosyncrasy, and sometimes from the exhaustion occasioned 
by previous or long-continued illness. 

LOCAL VARIETIES. 

ECZEMA CAPITIS. 

Syn. Vesicular scall ; Running sc all ; Erythema ichorosum ; Dartre 
S'juameuse humid e ; Porrigo asbestina. Tinea amiantacea ; Tinea 
furfuracea ; Alibert. Tinea granulata. 

Eczema capitis 1 presents the general characters of eczema rubrum, 
with excessive ichorous discharge; and sometimes, in an aggravated 
form running into eczema impetiginodes, complicated by its special 
seat of development on the hairy scalp, from which it is apt to extend 
to the forehead and temples, the ears, and nape of the neck. The 
scalp is red and swollen, and the cuticle cracked in every direction, 
and more or less raised from the inflamed surface beneath by ichorous 
secretion. The quantity of ichorous fluid is excessive, filling the hair 
with moisture, and distilling in little rills from beneath it; at first it 
is transparent and colorless, but viscous and tenacious; by degrees it 
becomes opaline and milky {tinea mucosa), and later in the progress of 
the disease, semipurulent, with the addition, here and there, of an 
admixture of blood. The hair soon becomes matted and agglutinated 
by the morbid secretions, and the latter dry up into thick, greenish, 
and yellow crusts, blackened here and there by the presence of blood. 

1 Portraits of Diseases of the Skin, Plate IV., AX. 



ECZEMATOUS OR tESICULAR ERUPTIONS. 201 

Wherever the crust breaks, new discharges issue from the openings, 
and still further augment and consolidate the mass, reeking and fetid 
with the accumulated secretions. The odor of the head when in this 
state is valerianic and peculiarly offensive, and nothing can be effected 
in the treatment of the disease until the filthy mass is removed. 

When the hair is sufficiently short from the first to prevent the 
excessive accumulation here described, a curious phenomenon occa- 
sionally presents itself. The crust having become desiccated over the 
surface of the scalp, necessarily contracts, and the contraction results 
in the fracture of the crust into polyhedral fragments or divisions, 
which resemble so many small islands, covering the head ; each of 
these little islands has its own proper portion of hairs, and these hairs, 
by the further contraction of the fragment, are drawn together, and 
form a conical pencil. All the hairs of the head may in this manner 
be collected. into conical bundles, and present a very singular appear- 
ance. The next thing that happens is equally curious. The ichorous 
secretion flows down these cones, and drips from their extremity ; and 
when the secretion subsequently dries, each cone is seen to be inclosed 
in a thin, transparent, glistening sheath, the hairs included within the 
sheath having the appearance of asbestos. Rayer compares them very 
aptly to the " pellicles that envelop the sprouting feathers of young 
birds." This is the origin of the terms teigne amiantacSe and p or rig o 
asbestina, bestowed by Alibert on eczema capitis, and is another 
instance of the extreme absurdity of dermatographical nomenclature. 

At a later period of the complaint, when the morbid secretions 
have diminished in quantity, the crust which is produced is of a dull 
gray color, and more friable than the crust previously described. 
This grayish crust, broken into fragments, or rather into granules, and 
dispersed among the hair, has been compared to particles of 'mortar, 
and suggested the term tinea granulata. Sometimes these little masses 
or granules, being pierced by the hairs, have the appearance of being 
threaded on them like beads upon a string. 

Eczema capitis is apt to become chronic, and, having ceased to pour 
out an ichorous secretion, produces a desquamation of furfuraceous 
scales in large quantity ; this is tinea furfuraeea. Later still, the 
erythema and parched state of skin remaining, the desquamation is 
mealy instead of being furfuraceous or branny, and the disease has 
become pityriasis capitis. 

Not uncommonly the persistent inflammation of the skin, which 
accompanies chronic eczema, causes destruction of the hair, and pro- 
duces partial alopecia. Sometimes, but rarely, the vitality of the 
scalp is so much injured that the growth of the hair is permanently 
arrested. At all stages of the disease the lymphatic glands of the 
occipital, auricular, cervical, and sub-mental regions are apt to enlarge 
and become painful ; sometimes to suppurate. 

Eczema faciki. — Eczema, when it attacks the face, is most fre- 
quently met with on the forehead, the chin, the eyelids and cheeks, 
and around the mouth. It presents no special features calling for 
attention, and is apt, when it attacks the eyelids and mouth, to pass 
into the chronic form. 



202 DISEASES ARISING FROAf GENERAL CAUSES. 

Eczema atrium. — Eczema makes its attack upon the ears at all 
periods of life, and in both sexes, and is not unfrequently met with in 
children during dentition. The ears affected by this disease are red, 
swollen, and tender, and are covered with excoriations and chaps, 
which pour out a profusion of ichorous fluid. The discharge spread- 
ing upon the inflamed surface desiccates into a yellowish and brownish 
lamella ted crust, which is constantly augmented by fresh secretion. 
From the pinna the inflammation often extends into the meatus, and 
gives rise to great pain. Small subcutaneous abscesses form in the 
integument around the ears, and the neighboring lymphatic glands 
enlarge. 

When eczema aurium assumes the chronic form, the quantity of se- 
cretion becomes less, the incrustations are thinner and less abundant; 
the tissues of the ear are swollen and thickened; the meatus is con- 
stricted ; the skin fissured by painful chaps ; and the djgease is ex- 
tremely obstinate ; often resisting every method of treatment, and 
enduring for years. 

Eczema mammilarum. — Eczema of the nipples is a somewhat 
rare variety of eczematous affection, and usually assumes a chronic 
form. It has been occasionally observed in women during suckling, 
but is more frequently met with in girls at puberty, in women who 
have never been mothers, at the critical period of life, and in old 
persons. It is characterized by an eruption of small vesicles, suc- 
ceeded by chaps, both the one and the other exuding a considerable 
quantity of secretion, which desiccates into lamellar scabs and scales. 
The affection is attended with much itching, and the nipple is tender, 
and frequently bleeds on being rubbed or scratched. In the chronic 
form the disease is exceedingly obstinate and difficult of cure. When 
it occurs during lactation it is desirable that the infant should be 
weaned. 

Eczema pudendi. — In this affection the eczematous eruption is 
developed upon the scrotum in the first instance, and thence extends 
to the neighboring parts of the thighs and to the anus; or it may 
commence in the latter situation, and spread to the scrotum. The 
disease, whatever its mode of origin, is exceedingly distressing, being 
accompanied by a most unbearable pruritus, which is increased rather 
than mitigated by the efforts of the, patient to relieve himself by 
scratching. The vesicles burst or are ruptured as soon as formed, a 
large quantity of ichorous secretion is poured out, fissures and exco- 
riations are produced, and great suffering is the consequence. Eczema 
in this region generally assumes the chronic form, and continues, with 
temporary remission in the severity of the symptoms, for months and 
yea is. It is generally met with in persons of the middle period of life. 

In the female, eczema pudendi is, if possible, more painful and 
distressing than in the male, and is much heightened by the extension 
of the eruption to the mucous membrane of the vulva. The irritation 
is, moreover, augmented by the frequent discharge of morbid secre- 
tions from the vagina. All the functions of the region are rendered 
painful, the smarting is excessive, and the pruritus unbearable. Adults 



ECZEMATOUS OR VESICULAR ERUPTIONS. 203 

are most frequently attacked with this disease, and children rarely. I 
have, however, seen one instance in a little girl eight years of age. 

Eczema articulorum. — As before remarked, eczema of the flexures 
of the joints is a common complication of general eczema ; so that 
where the latter is present, the thin skin of the bends of the joints is 
sure to be affected to a greater or less degree. In chronic eczema, 
again, the eruption lingers about the joints after it has disappeared 
from other parts of the body. And sometimes the eruption is, from 
the first, limited to the joints. When the latter is the case, the disease 
may present itself in the form of eczema simplex or eczema rubrum ; 
and at a later period it may become a confirmed eczema chronicum 
or psoriasis. As eczema chronicum or psoriasis, the integument is 
thickened, red, dry, hot, and contracted, cracked into fissures which 
bleed whenever the joint is stretched, and roughened by a more or 
less copious laminated or furfuraceous desquamation. When eczema 
rubrum has got well, the skin remains congested for some time after- 
wards, it looks tender and wrinkled, and is covered by a thin, trans- 
parent, and polished cuticle. 

Eczema m^nuum et pedum. — Eczema of the hands and feet is 
similar in its characters ; but, from exposure to the atmosphere, the 
disease is more common in the former than in the latter. The com- 
mon seat of the eruption is the back of the hand, where it resembles 
lichen agrius, and in its chronic state becomes psoriasis dorsi manus. 
Eczema appears on the back of the hands in its simple vesicular form, 
as when excited by the sun's rays, eczema solar e ; but it is more com- 
monly met with as eczema rubrum, with the characters common to 
that stage of the affection, namely, slight tumefaction, cracked, exco- 
riated, and softened cuticle, and a profusion of transparent, ichorous, 
and viscous discharge, which may be seen distilling from the exposed 
and congested derma, and oozing from numerous smaller points, where 
the cuticle has been removed by friction or scratching. Later in the 
course of the disease the eczema becomes chronic, the ichorous dis- 
charge diminishes in quantity, or ceases altogether, and the surface 
becomes coated over with thin crusts and scales. 

Not unfrequently the disease is met with on the hands under the 
form of eczema digitorum, appearing towards the end and upon the 
tips of the fingers, and attended with much suffering from itching, 
tingling, smarting, burning, and extreme tenderness. It commonly 
happens that no trace of eczema or eruption exists upon any other 
part of the body, and the small extent of the disease becomes remark- 
able. Sometimes a single finger only is attacked, sometimes the same 
finger on both hands; and although trilling in itself, it is a source of 
great annoyance to the patient, not only from the pain which it excites, 
but from its unsightly appearance and obstinate persistence. This 
troublesome eruption commences with a feeling of itching in the part; 
when scratched or rubbed there is a sensation of hard granules under 
the skin ; and, upon close inspection, the cuticle will be seen to be 
studded with dark, transparent, circular spots, evidently drops of 
effused lymph, which, from the thickness of the epidermis, are unable 



204 DISEASES ARISING FROM GENERAL CAUSES. 

to arise it into vesicles. On the backs of the fingers and around the 
nails, true vesicles are formed, which are sometimes numerous, and 
sometimes, by communication with each other, raise up the cuticle to 
a considerable extent, and finally cause its exfoliation. In mild forms 
of the complaint, the fluid of the vesicles is absorbed, and the cuticle 
desiccates into a thick, yellowish, and horny layer ; sometimes the 
disease passes into the chronic form, the skin becomes thickened, dry, 
and cracked, the cuticle exfoliates repeatedly, and the morbid action 
is perpetuated as a chronic eczema digitorum. When the disease 
fixes on the thin skin at the ends of the fingers, the nail is sometimes 
destroyed. 

Eczema rubrum dorsi manus disputes with lichen agrius dorsi 
manus, the popular titles of grocers' itch and bricklayers itch ; and it is 
often a point of nice distinction to determine whether to call a given 
eruption, eczema or lichen agrius, lichen eczematosus, as it might 
with great propriety be called. 

Diagnosis. — The different varieties of eczema present differences 
of character which are peculiar to themselves, and must be borne in 
mind in our endeavors to establish the diagnostic signs of the disease. 
Thus, in eczema simplex we find clusters of minute vesicles in great 
numbers, and without accompanying redness ; in eczema rubrum the 
vesicles are surrounded by inflamed areolae of considerable extent, and 
mingled Avith moist excoriations ; in eczema impetiginodes many of 
the vesicles contain a purulent fluid, others are ichorous, and others, 
again, are supplanted by excoriated patches; in the latter stages of 
all the above varieties, we find lamellated scabs and incrustations of 
variable thickness ; and in eczema chronicum, or psoriasis, we have 
chaps and fissures pouring out an ichorous fluid, and, at a later period, 
copious desquamation. Moreover, eczema is frequently seen as a 
complication of scabies, and is itself complicated with the pustules of 
impetigo and ecthyma. 

Eczema simplex is not unfrequently confounded with scabies, and 
from the similarity of some of their characters, this mistake is likely 
to occur. In both, there are vesicles ; in both, the eruption is developed 
without redness ; both are situated in the flexures of joints, between 
the fingers, &c. ; and both are accompanied with pruritus. But, upon 
careful examination, considerable differences will be detected between 
the two diseases. 

Simple eczema is likely to be confounded with sudamina, with 
which its vesicles bear considerable analogy. The characters by which 
it may be distinguished are, that, in the latter, the vesicles are of larger 
size than those of eczema, being equal in bulk to a millet seed, while 
those of eczema rarely surpass the head of a small pin. The vesicles 
of sudamina are scattered and discrete ; those of eczema, confluent and 
aggregated. The former are associated with profuse perspiration, 
which is not the case with eczema. Moreover, sudamina occur with- 
out preceding irritation of the skin, and their presence gives rise to 
no abnormal sensations. 

Eczemaimpetiginodes is liable to be mistaken for scabies and impetigo. 



ECZEMATOUS OR VESICULAR ERUPTIONS. 205 

Scabies complicated with pustules, as it sometimes occurs, presents 
several points of resemblance with eczema impetiginodes, but the other 
characteristic signs, and the presence of a parasitic animalcule, are 
absent. The pustules of scabies, again, contain pus from their first 
appearance. In impetigo, the pustules never contain lymph; they 
are larger than the eczematous lymph-pustules, unmixed with vesicles, 
and confined to a small extent of surface. Again, the hardened cover- 
ings of the excoriations of eczema are thin scabs, while those of im- 
petigo are dense and thick greenish-yellow or brownish crusts. 

Eczema chronicum presents many points of resemblance with lichen 
agrius ; for instance, the chaps and fissures, the ichorous secretion 
from the excoriated surfaces, and the copious exfoliation of scales. 
Indeed it is only by means of the previous history of the eruption that 
their diagnosis can be determined. The result of the diagnosis is, 
however, of little consequence, as both, at this stage, come under the 
designation of psoriasis. 

Eczema capitis is sufficiently distinguished from other diseases of 
the scalp by the characters which have been already indicated. 

Eczema aurium is distinguished from erythema intertrigo by the 
absence of all trace of vesicles in the latter, and by its sole appearance 
in the cleft behind the ears. It is attended with chapping, and by the 
effusion of ichorous discharge. The same characters serve to establish 
the diagnosis between eczema mammillarum, pudendi, and articulorum, 
and erythema of those regions. 

Causes. — Eczema is apt to occur either symptomatically, as a con- 
sequence of some constitutional disturbance, or as an effect of the 
application of local irritants to the surface of the skin. Of the former 
kind are the changes which take place in the system under hygienic 
influences, as during the spring and summer season of the year, par- 
ticularly when accompanied by atmospheric vicissitudes ; affections 
of the digestive system, as dentition, the irritation produced by unsound 
milk in infants at the breast, and stimulating and improper food and 
drinks in persons of all ages ; affections of the uterine system, as 
amenorrhoca, dysmenorrhoea, utero-gestation, and the critical period 
of life ; the cessation of lactation ; affections of the nutritive system, as 
scrofula ; and affections of the nervous system, as mental emotions, 
particularly of the depressing kind. The local causes of the disease 
are heat and cold, together with friction, and irritation of the skin 
produced by whatever cause. Thus, occasionally, we find eczema 
resulting from exposure to the sun's rays, a variety which has been 
denominated eczema solare. It not unfrequently attends the inflam- 
mation produced upon the skin by the irritation of a blister, or by the 
application of the compound sulphur ointment, or of a pitch plaster. 
A variety is also met with affecting the hands of persons who are 
called upon, in the ordinary occupation of life, to manipulate dry and 
powdery or stimulating substances. In the same category must be 
enumerated the transmission of eczema, by contact, from one person 
to another, the discharge from the vesicles in this case not effecting 
any specific action, but merely acting the part of a local irritant. 
Eczema is developed in females more frequently than in males, an 



206 DISEASES ARISING FROM GEXERAL CAUSES. 

observation which must be referred for its explanation to the greater 
cutaneous susceptibility of the former than of the latter sex. Again, 
different parts of the body exhibit a greater or less disposition to the 
invasion of the disease at different periods of life; hence it is well 
remarked by Rayer, that in "infancy and youth, eczema appears more 
particularly on the head ; in riper years, on the breast and belly, but 
especially on the genital organs ; and in advanced life, on the lower 
extremities, and about the margin of the anus." In some instances 
the eruption has been observed to be hereditary in its origin, being 
developed in the infant soon after birth, and after the previous occur- 
rence of the disorder in the parent. 

Prognosis. — Eczema acts very commonly as a safety-valve to the 
health of the system, and the discharge by which it is accompanied 
must be checked very guardedly, and not before a counteraction, 
either on the skin or on the alimentary mucous membrane, has been 
established by art. In most instances the eruption is difficult of cure, 
not so much from any pathological peculiarities which it presents, as 
from the circumstance of *Js being symptomatic of constitutional dis- 
turbance, or visceral disease, which must be removed before the local 
affection can be conquered ; indeed, it usually happens that the cure of 
the constitutional disorder is followed by a spontaneous disappearance 
of the eczema. 

Treatment. — Eczema must be treated in accordance with the prin- 
ciples laid clown in the chapter on general therapeutics, and the three 
indications therein announced must be observed. Elimination must 
be effected by means of aperients, the compound colocynth pill, with 
soap or henbane, and if thought necessary, calomel or blue pill ; sul- 
phate and carbonate of magnesia, with nitrate of potash and mint 
water, or any more convenient form. If there be fever, effervescent 
salines are the proper remedy ; if there be an excess of acid salts in 
the system, with symptoms of rheumatism, neuralgia, or gout, then 
alkalies with bitters should be given, and a grain of the acetous ex- 
tract of colchicum conjoined with the aperient pill. 

Restoration of power, the second indication, is to be attained by 
means of tonic remedies, one while conjoined with alkalies, if the acid 
diathesis prevail ; and then with the mineral acids, nitromuriatic and 
sulphuric. If there be debility, with languor, lassitude, and depres- 
sion of spirits, the plan of bitters with acids is the correct one to 
pursue. Later in the course of the disease, when it has proved rebel- 
lious to treatment by general remedies, or has passed into the 
chronic stage, and is established as a chronic disease, we may have 
recourse to the specific powers of arsenic. Three to five minims of 
Fowler's solution, or six to ten of the acid solution of De Valangin, 
may be given three times a day, with meals; and in very chronic 
cases, when the conjunction of mercury and iodine with arsenic is 
thought desirable, ten minims of Donovan's solution may be taken 
with meals, also three times a day. When chronic eczema resists every 
other mode of treatment, it may be assailed by the tincture of can- 
tharides exhibited in combination with compound tincture of camphor 



ECZBMATOUS OR VESICULAR ERUPTIONS. 207 

and bark. In these very obstinate cases the bichloride of mercury in 
tincture of bark has sometimes been found of great service. 

In the exhibition of arsenic, the known irritative effects of that 
medicine when taken for too long a time, in excess, or by persons 
intolerant of the remedy, must be borne in mind and carefully watched, 
and the instant any of these symptoms occur, the remedy must be 
suspended. The same remarks apply to the administration of can- 
tharides. The rule that I lay down for the guidance of my patient 
while taking arsenic is simply this : If you feel ill from any cause what- 
ever , think you have taken cold, or have any pains in your stomach, 
immediately stop the medicine until those symptoms have subsided ; and 
then resume it as before. By obeying these instructions the patient will 
avoid all danger from harm, while taking an excellent medicine. 

. The third indication, the alleviation of local distress, in other words, 
the local treatment, brings us to operate with those topical applications 
which are known to soothe a part in the state of inflammation ; the 
first of them is water-dressing, the second a soothing unirritating 
ointment, such as the benzoated ointment^of oxide of zinc, rubbed 
down with spirits of wine, a drachm of spirit to the ounce, and perfectly 
fresh. When the water-dressing is used, the intention should be to 
reduce the local congestion and suffering, and encourage discharge. 
As soon as that end is attained, we must endeavor to arrest discharge, 
and heal the excoriated skin ; then is the time for the oxide of zinc 
ointment, and then it is unfailing, if properly applied. 

In eczema simplex, the lotio plumbi may be found useful, and if 
there be much pruritus, a lotion of sesquicarbonate of ammonia, a 
drachm to the half pint; an emulsion of bitter almouds with hydro- 
cyanic acid ; a lotion of the liquor ammoniae acetatis with camphor 
mixture ; a liniment of olive oil and lime-water with liquor plumbi ; 
simple cerate with camphor ; the oxide of zinc ointment, with spirits 
of wine or camphor, or the unguentum plumbi compositum. 

In eczema rubrum and eczema impetiginodes, after the heat and 
inflammation of the skin have been sufficiently reduced by water- 
dressing, the benzoated ointment of oxide of zinc should be applied 
somewhat thickly over the whole surface, so that every holloAv and 
recess may receive its share, then a piece of linen rag thinly spread 
with the same ointment, or a sheet of cotton-wool, should be laid over 
the part. This kind of dressing should be repeated once or twice 
a day, and to uncovered parts as often as the ointment may be acci- 
dentally disturbed or rubbed off. At first, and while the skin is in a 
state of inflammation, the ointment cannot be applied too lightly; later 
in the course of the disease a little friction may be used; and later 
still, when crusts have formed on the eruption, a gentle effort may be 
made, while applying the ointment, to displace the crusts with the 
finger daring the act of friction. Throughout the whole period of 
treatment of the eruption by ointment no water should be used, and 
consequently no washing. Occasionally, when the crusts and ointment 
have accumulated unduly, the part may be sponged with warm water, 
and immediately after anointed afresh, but generally, washing is 
mischievous rather than beneficial. 



208 DISEASES ARISING FROM GENERAL CAUSES. 

If heat and inflammation occur during the treatment of the part by 
inunction, there is nothing to prevent the application of strips of rag 
wetted with evaporating lotion externally to the covering which keeps 
the ointment in its place ; and other means of relief, such as position 
or fomentation, may also be adopted. Sometimes when the tone of 
the skin has been much lowered by the continuance of the disease, or 
the prolonged use of water-dressing, and particularly when the lower 
extremities are the seat of the eruption, a bandage, to make a firm 
and equable pressure on the surface of the limb, may be used with 
advantage. 

In chronic eczema other topical remedies are required, one while to 
relieve pruritus, and another while to exert a discutient action on the 
affected part. The juniper tar-ointment, considerably diluted, is an 
excellent anti-pruritic remedy, while, stronger, or of its full strength, 
it is powerfully discutient. Among the best of the discutient remedies 
are the ointments of the nitric and hydrochloric salts of mercury, 
variously diluted ; for example, the nitric oxide of mercury, unguen- 
tum hydrargyri nitratis, and unguentum hydrargyri ammonio-chloridi. 
In some forms of chronic eczema one or other of these ointments is 
specific ; for example, the unguentum hydrargyri nitrico-oxydi diluted 
to the extent of one part in four, in pityriasis capitis ; the unguentum 
hydrargyri nitratis, one part in eight, in psoriasis palpebrarum, &c. 

Sometimes eczema rubrum and eczema impetiginodes, when of long 
continuance, or when the water-di'essing or poultice have been unduly 
prolonged, become excessively tender, so tender, in fact, as to be irri- 
tated by the mildest application. I have such a case in remembrance, 
wherein the disease of the skin was rendered most distressing by its 
association with cutaneous neuralgia ; and I have since seen several 
cases of a similar kind. In this morbidly sensitive state of the skin 
and of the eruption, I have found no remedy act so well as a solution 
of nitrate of silver in spiritus setheris nitrici, in the proportion of one 
grain to the ounce. 

SUDAMINA. 

Syn. Miliary vesicles. Miliaria. Miliary eruption. Hydroa. Herpes 
miliaris. Die Friselblattem ; die Schweisblattern, Germ. 

Sudamina are small prominent vesicles, of a rounded form, and 
about equal in size to millet seeds. They are transparent at first, and 
have a pinkish hue (miliaria rubra), but at the end of twelve or twen- 
ty-four hours, become opaque and milky (miliaria alba), and resemble 
small pearls scattered on the skin. Their period of duration is three 
or four days ; they then shrivel and dry up, and form thin scabs, 
which are tin-own. off by desquamation. By successive attacks the 
eruption may be continued for several weeks. 

Sudamina may be situated on any part of the body; their most 
frequent seat being the trunk, where they usually occupy a district of 
considerable extent; and select by preference the side of the thorax, 
the axillae, and the adjacent part of the inside of the arm ; being no 
doubt encouraged by the heat of this region. They are always discrete. 



ECZEMATOUS OR VESICULAR ERUPTIONS. 209 

though sometimes very numerous, are preceded by no signs, or by 
very little indication of cutaneous irritation, and by trifling redness of 
the skin. 

Sudamina have received their name from being always associated 
with excessive heat of the skin, and often with profuse perspiration. 
Hence they are occasionally met with in eruptive fevers, namely, in 
rubeola, scarlatina, and variola. They also accompany simple, remit- 
tent, and typhoid fevers, and most inflammatory affections accom- 
panied with profuse perspirations, as acute rheumatism. From the 
size which they usually present, namely, that of a millet seed, they 
have been termed miliary vesicles, hence the* specific designation 
attached to certain diseases, as erythema miliare, implies a complica- 
tion by these vesicles. Sudamina are most frequently observed in 
persons possessing a thin and irritable skin, and during the summer 
season. 

Since the days of Sydenham, who advocated so powerfully the 
adoption of a cool temperature and cooling regimen in fevers, sudamina 
have become rare ; but previously to his time they were exceedingly 
frequent, and, from their connection with fever, were regarded as a 
specific disorder, preceded and accompanied by severe and dangerous 
fever. This fever was termed miliaria, and for many years was 
regarded as a dangerous and fatal disease, spreading like an epidemic, 
and destroying multitudes of lives. But, as I before remarked, since 
a more rational method of treatment has been employed in medicine, 
miliary fever has ceased to exist. Bateman remarks, " It is scarcely 
necessary now to enter into any detail of proofs that the miliary erup- 
tion is the result of a highly heated and perspiring state of the skin, 
and that in its severe and fatal degree it is solely the effect of a stimu- 
lating regimen in a confined atmosphere. The almost total annihila- 
tion of the disease, of late years, since the general adoption of a better 
practice, is of itself unequivocal evidence of its origin." "Hippo- 
crates, whose mode of treatment in febrile diseases was not calculated 
to produce excitement, has once or twice, but casually, mentioned the 
miliary eruption. And again, at the latter part of the seventeenth 
century, when, in the practice of the majority of physicians, the miliary 
fever was a frequent and fatal occurrence, Sydenham witnessed no 
such fever ; but mentions the occasional appearance only of miliary 
vesicles, which he ascribes to their proper cause." 1 

"Among the various circumstances," continues Bateman, "under 
which the miliaria was formerly excited, the puerperal state appears 
to have been most frequently the source of it ; insomuch that it was 
first described as an epidemic among puerperal women. This is suffi- 
ciently accounted for by the treatment which was unhappily pursued 
during the confinement after childbirth, and of which an impressive 
description is given by Mr. White. For not only was the mother im- 
mediately loaded with bedclothes, from which she was not allowed to 
put out 'even her nose,' and supplied with heating liquors from the 
spout of a teapot ; but to her room, heated by a crowd of visitors and 

1 Synopsis, edited by Dr. Thomson, p. 348. 
14 



210 DISEASES ARISING FROM GENERAL CAUSES. 

a fire, all access of air was denied, even through a keyhole. From 
these causes fever was almost necessarily induced, with the most pro- 
fuse sweats, oppression, anxiety, and fainting ; and these again, were 
aggravated by spicy caudles, spirits, opiates, and ammoniacal medicines. 
That numbers should perish under such management, with every 
symptom of malignity, and that many who survived it should escape 
with broken constitutions, will surprise no person who is acquainted 
with the baneful influence of overexcitement in febrile complaints." 1 

Diagnosis. — The diagnosis of miliary vesicles is not difficult ; their 
being discrete, though numerous ; their form and size ; their occur- 
rence chiefly on the trunk of the body ; the absence of inflammatory 
redness of the skin ; and their association with constitutional disease, 
and generally with a clinical state of the patient, sufficiently distin- 
guishing them from the smaller, itching and tingling, clustered vesi- 
cles of eczema. The seat of eczema, again, is so different, and the 
inflammation of the skin which generally surrounds the vesicles. 
The vesicles of herpes are too large, and the inflammation at their 
base too conspicuous to be confounded with sudamina. 

The causes of sudamina have been sufficiently indicated in the pre- 
ceding description, and the prognosis must depend upon the disease 
with which they are associated, and of which they are simply symp- 
tomatic. 

The treatment, again, applies to the fever which they accompany. 
The vesicles are too insignificant to call for the use of therapeutic- 
measures. 



CHAPTER VIII. 

DISEASES ARISING FROM GENERAL CAUSES. 
IMPETIGINOUS OR PUSTULAR ERUPTIONS. 

Under the influence of a degree of inflammation of the derma, for 
the most part greater, at least at its commencement, than that which 
exists in the eczematous group of diseases, the inflamed derma gives 
rise to the formation of pus ; the pus occupying the surface of the 
derma, and producing an elevation of the epidermis to a limited ex- 
tent. This irregularity of the surface of the skin, namely, an eleva- 
tion of the epidermis consequent on the presence of pus, is termed a 
pustule, and this is the only accurate sense in which that term can be 
employed. There is a Avide distinction between a vesicle and a pus- 
tule, when these two pathological forms present their typical charac- 
ters ; but it not unfrequently happens, that, in consequence of a repa- 
rative action set up in the vesicle, pus is produced upon its dermal 

1 Synopsis, edited by Dr. Thomson, p. 350. 



IMPETIGINOUS OR PUSTULAR ERUPTIONS. 211 

base, and, mingling with the lymph, constitutes a semi-purulent, and 
subsequently a purulent or pustular vesicle. In such a case it is 
necessary to remember that a true pustule contains pus from the first 
moment of its formation, and, by this circumstance, is essentially dis- 
tinguished from a vesicle. 

It is requisite, at the outset of our study of cutaneous diseases, to 
be precise in our definitions, and to draw as broad a line as possible 
between the various pathological forms which we are desirous of cha- 
racterizing. Scarcely any word in medical nomenclature has been 
used more loosely than the term pustule. At one time it -was em- 
ployed to signify a papula, at another a vesicle. 1 Willan employed 
it, with the characters above stated, as the type of his fifth order, pus- 
tulce ; and in this sense it has been subsequently adopted by succes- 
sive dermatologists. 

The diseases which I propose to consider under the definition above 
given, are two in number, namely, 

Impetigo, Ecthyma. 

The order Pustulae of Willan embraces five diseases, two of which, 
had he lived at the present time, would, I am convinced, have been 
excluded by himself, namely porrigo and scabies. The genus Porrigo 
of Willan contains diseases of the most opposite kind, and has been 
the source of much confusion, so much, indeed, that it would be well 
that the term should, for the future, become obsolete and forgotten. 2 
Scabies, again, is a disease possessing several elementary forms of 
which both vesicles and pustules are accidental, and only occasionally 
present ; the pustules, when they exist, belonging to ecthyma. 
Variola, as placed by Willan in the order pustulae, is forcibly torn 
from all its natural affinities, and for this reason I have thought it 
correct to transfer it to the group of eruptive fevers. Rayer admits 
no less than ten genera of pustular inflammations, for four of which 
he is indebted to variola, namely, variola, varicella, vaccinia, and 

1 Riolanus informs us that in his time (the sixteenth century), cutaneous diseases were 
grouped into three genera, according to their prominent characters in reference to smooth- 
ness, color, and magnitude; but as this arrangement excluded diseases of the hair, others 
preferred dividing them into pustules, deformities, and tubercles. The genus pustule 
comprehending all eruptions attended with roughness of the skin, whether pimples, vesi- 
cles, proper pustules, or scales. 

2 The diseases marked by roughness of the skin (asperitas cutis), the group of pustulse, 
present as a secondary group, scabies, an eruption attended with much itching, and ex- 
citing the "desiderium scabendi," hence its name. Scabies, again, has two species, hu- 
mid;! ci sicca; scabies bumida is the representative of eczema; and scabies sicca, which, 
besides being dry, is rough and pimply like goose-skin, seems to correspond with lichen. 
Bui BCabies sicca has twf) sub-genera which are scaly, and are therefore named psora, the 
parent <>(' the psoriasis of the present time; and psora is subdivided in reference to the 
bulk of its scales into psora porrigo, and psora lepra — the scales of the former being furfu- 
raceous, and of the latter as large and thick as lish-seales. We are thus enabled to trace 
the proper signification of porrigo; it is a dry furfuraceous eruption attended with itching; 
its furfuraceous quality being indicated by the first two syllables of the word; "a porro, 
quia ut pomnn in tunics involucra. ita entis velut in squamas resolvitur ;" and its pruritic 
character by the terminal .syllable, "quasi prurigo." Porrigo, therefore, corresponds with 
pityriasis; while porrigo capitaa is further named tinea, because the skin seems eroded 
like garments attacked with the moth. 



212 DISEASES ARISING FROM (iEXERAL CAUSES. 

vaccinella. There could have been no objection to thus establishing 
a distinct group of variolous affections, indeed, some benefit might 
have flowed from such an arrangement, but the possible advantages 
are immediately destroyed by the companionship with which he has 
leagued them. Thus, from the highly inflammatory and contagious 
fever of variola, we pass on immediately to three forms of disease of 
the face, two of which are affections of the sebiparous glands and hair 
follicles, namely, rosacea, acne, and sycosis ; next in order follows 
impetigo; then favus, a peculiar disease of the hair follicles; and 
lastly, ecthyma. 

The genera impetigo and ecthyma constitute the two essential forms 
of pustules indicated by Willan, namely, psydracia and phlyzacia, the 
former being a psydracious (4'uy.pa bdpdxta, frigidge guttulse) pustule, 
that is, kl a small pustule, often irregularly circumscribed, producing 
but a slight elevation of the cuticle, and terminating in a laminated 
scab. Many of the psydracia usually appear together, and become 
confluent ; and after the discharge of pus, they pour out a thin, watery 
humor, which frequently forms an irregular incrustation." The latter, 
a phlyzacious (pXbZeiv, to be hot) pustule; that is, one, " commonly of 
a large size, raised on a hard, circular base, of a vivid red color, and 
succeeded by a thick, hard, dark-colored scab." The achor and the 
favus of Willan are pustules developed around the mouths of the hair 
follicles on the scalp. 

IMPETIGO. 

Syn. Psydracia. Ecpyesia impetigo, Mason Good. Crusted tetter, or 
scall. Dartre crustacee, Fran. Kleienaussatz, Germ. Melitagra, 
Alibert. 

Impetigo 1 (Plate X., a-f) is a non-contagious inflammation of the 
skin, assuming usually a subacute type, and characterized by the 
eruption of small, hemispheroidal, or flattened pustules, with but little 
inflammation at their base. The pustules are for the most part 
arranged in thickly set clusters, which occupy a small extent of sur- 
face; at other times they are distributed more or less generally over 
the surface of the body. Each pustule attains its full development 
and bursts, in the course of two or three days, terminating in a rough, 
yellowish, and transparent crust, of considerable thickness. The dis- 
ease occurs frequently in successive crops, is attended with trifling or 
no constitutional symptoms, and endures from three to four weeks to 
as many months, and even years. 

The mode of distribution of the pustules has given rise to the divi- 
sion of the disease into two principal varieties, namely — 
Impetigo figurata, 
" sparsa. 

To these have been added, by Willan, other varieties, respective of 
degree of severity or locality, which it Avould be more desirable to 

1 Impetigo, ab impelu, according to Pliny. Impetu agens. 






IMPETIGINOUS OR PUSTULAR ERUPTIONS. 213 

consider as sub-varieties under the above heads ; one of these, impetigo 
rodens, I omit altogether from consideration, since the disease described 
by Bateman under this name is evidently a syphilitic ulceration of the 
skin, and not an impetigo. The remaining varieties are — 

Impetigo scabida, 

" erythematica, 
" capitis. 

IMPETIGO FIGURATA. 

Syn. Dartre crustacee flavescente, Alibert. 

This variety (Plate X., a b) is characterized by the occurrence of 
the eruption upon a distinctly circumscribed and defined spot, which 
is usually circular on the face and upper parts of the body, and oval 
on the lower extremities. The disease commences with the appear- 
ance of one or several small patches of redness, which remain distinct 
throughout the progress of the eruption, or subsequently unite with 
each other, and constitute a single patch ; or it may appear at once 
as an inflamed patch of considerable size. Upon this inflamed patch 
a crop of small yellow pustules are developed, which rise but slightly 
above the surface of the skin, and are collected into thickly set and 
sometimes confluent clusters. At the 'end of one, two, or three days, 
the pustules burst and discharge their contents, and the effused fluid 
desiccates into thick, brittle, greenish-yellow colored crusts, resembling 
a patch of dried honey. Beneath the crust the surface is red, inflamed, 
and excoriated, and pours out an abundant semi-purulent viscous 
ichor, 1 which contributes still more to the thickness of the crust. 
Unless prolonged by successive eruptions, the crust falls off in from 
two to four weeks, leaving the surface beneath of a vivid red color, 
somewhat swollen, exceedingly tender, and covered with a thin and 
shining epidermis. The surface is occasionally fissured by the move- 
ments of the part, and a secretion is poured out, which hardens into 
a thin secondary crust, and is followed by successive laminae, formed 
in the same way. When the whole of the original patch is concealed 
by the kind of incrustation above described, the character of the 
disease may still be distinguished by a few scattered pustules, which 
always appear around the circumference of the crust. As the 
disease progresses towards cure the semi-purulent ichorous secretion 
diminishes by degree's, and ultimately ceases; the crusts are no 
longer augmented in thickness ; the secondary crusts, which have 
become progressively thinner, cease to be formed; and the skin, 
which is left red and congested, returns, after a certain space of time, 
to its original color and pliancy. 

Constitutional symptoms are cither very slight in impetigo, being 
limited to sonic degree of lassitude and headache, or they are absent 
altogether. The local symptoms consist of heat and itching, which 
are much increased, and accompanied by a feeling of tension and 

1 Mason Good 1ms given the terms " running scull and bumid scall" to impetigo; both, 
however, more firoperly belong to eczema. 



214 DISEASES ARISING FROM GENERAL CAUSES. 

smarting during the pustular stage. After the formation of the 
crusts these symptoms gradually subside, but the skin remains tender 
for some time after their fall, and very susceptible of a return of the 
eruption, if exposed to fresh irritation. 

Impetigo figurata presents various modifications in relation to the 
extent of surface affected, and the course of the disease. Sometimes 
it is confined to a very limited space, as to the middle of one cheek, 
the upper lip, the nose, or one or both eyelids, while, at other times, 
it fixes at once upon the entire face. Sometimes the eruption 
occupies a patch of small size in the first instance, while the disease 
spreads by its circumference (impetiginous ringworm), so as eventually 
to cover a large surface, whereof the centre presents the crusted stage 
of the affection, and the periphery its erythematous and pustular 
stages. The crusts again occasionally offer a peculiarity of appear- 
ance, being conical in their shape, and compared by Alibert to 
stalactites. This variety he terms dartre crustacee stalactiforme ; it is 
most frequently seen upon the eyelids, borders of the eyebrows, 
nose, &c; in brief, in any situation where the effused secretion has an 
inclination favorable to the gravitation of the fluid from the surface of 
the skin. 

Instead of running through its course, and terminating by the 
restoration of the skin to soundness, within a moderate period, 
impetigo figurata is sometimes prolonged indefinitely by successive 
eruptions of pustules, each eruption pursuing the natural course of the 
typical affection. These successive attacks are occasioned either 
by a continuance of the original cause of the disorder, or by 
the employment of stimulating and irritating substances for its cure. 
In such cases the morbid action extends to the deeper tissues of the 
skin, producing thickening and condensation of the integument. 
Again, the eruption may occur periodically, appearing in the spring 
or autumn season for several successive years. 

The most frequent seat of impetigo figurata is the face, and more 
particularly the cheeks, but it may also occur upon the trunk of the 
body and extremities. The forearms I have remarked to be a not 
unusual position of the eruption. It commonly appears on several 
regions at the same time, and there exists some little difference in 
regard to the form of the patch, according as it may be developed on 
the upper or the lower extremities ; thus, on the former, it approaches 
near the circular, on the latter, the oval shape. 

Impetigo figurata sometimes assumes a chronic form; fresh crops of 
pustules are no longer produced, but the integument takes on a morbid 
action^it becomes thickened and infiltrated, mid the excoriated surfaces 
pour out a viscous, semi-purulent secretion, which desiccates into 
fresh incrustations, the incrustations being reproduced as often as they 
are rubbed or thrown off. Occasionally the incrustations, instead of 
being thrown off, form a thick case upon the part affected or around 
the limb, and constitute that variety which has been denominated, by 
VVillan, impetigo scabida. A limb surrounded by a case of incrustation 
of this kind, has been compared, very aptly, to the trunk of a tree 
covered with a rou^h and cracked bark. 



IMPETIGINOUS OR PUSTULAR ERUPTIONS. 215 



IMPETIGO SPARSA. 

Syn. Scattered crusted scall, or tetter. 

Impetigo sparsa (Plate X., c) differs from impetigo figurata only in 
the more disseminated arrangement of the pustules. Instead of being 
confined, as in the latter, to a single spot or region, they are, in the 
sprinkled form, distributed over a considerable surface ; for instance, 
over an entire limb, and sometimes over the whole body. The eruptive 
process pursues precisely the same course with that described as the 
typical form of the preceding variety ; it is attended with considerable 
pruritus, and the pustules are successive, being freshly developed in 
the midst of fully formed crusts. Impetigo sparsa usually appears on 
the limbs, especially on the lower extremities and about the ankles, 
and is frequently seen in the neighborhood of joints. On the legs it 
is not unfrequently associated with oedema, and is exceedingly trouble- 
some. 

Impetigo sparsa is more apt to degenerate into the chronic form 
than the preceding variety. The surface beneath the crusts often pre- 
sents superficial ulcerations, the integument becomes thickened and 
infiltrated, and the large collections of crusts constituting impetigo 
scabida, are more frequently produced. 

IMPETIGO SCABIDA. 

Impetigo scabida (Plate X., f) is merely that state of the two pre- 
ceding varieties in which the surface is covered by a thick incrusta- 
tion resembling the rough bark of a tree. This crust is broken and 
fissured from point to point by the movements of the part, and 
through the apertures a quantity of semi-purulent secretion oozes to 
the surface, and desiccates on the exterior of the crust. Sometimes 
impetigo scabida occurs upon the face, forming a complete mask to the 
features, but generally it is seen only on the limbs, and accompanies 
the chronic form of the eruption. It is attended with much pain in 
moving the limb, and by troublesome pruritus. When the crust is 
removed, the surface beneath is observed to be excoriated by super- 
ficial ulcerations, and fresh incrustations are speedily formed. Impe- 
tigo scabida is for the most part met with in old persons, and in those 
of debilitated constitution, and is not unfrequently associated with 
oedema. 

IMPETIGO ERYTHEMATICA. 

Impetigo erysipelatodes. Erythematic scall. 

The ordinary forms of impetigo are characterized by the absence 
of constitutional symptoms, and by the moderate degree of inflamma- 
tion which accompanies the local disease. Sometimes, however, the 
eruption is preceded by burning heat of surface, tension, great red- 
ness, tumefaction ; m short, by the usual signs of acute erythema. To 
these are added fever, and considerable constitutional disturbance, the 
eruption appearing as usual, and running the same course. It is upon 
this combination of symptoms that Willan has bestowed the designa- 



216 DISEASES ARISING FROM GENERAL CAUSES. 

tion of impetigo erysipelatodes, which I have ventured to correct by 
changing the name to impetigo erythematica. 

IMPETIGO CAPITIS. 

Impetigo capitis may present itself to our observation, either in its 
aggregated or its scattered form ; and it may be developed at once 
upon the entire head, or make its appearance separately on the scalp, 
the face, or the ears. The aggregated form of the disease, impetigo 
figurata, may be looked upon as an advanced stage of eczema impeti- 
ginodes, or an eczema rubrum bursting into existence with a crop of 
pustules instead of vesicles ; as, in fact, an eczema occurring in a pyo- 
genic constitution. Hence, when impetigo capitis is severe, the local 
state and symptoms so closely resemble eczema impetiginodes, as to 
force upon the mind the impression of their being the same disease ; 
and, as far as their management is concerned, their treatment must be 
precisely the same. 

Impetigo figurata being an eruption of pustules, and the discharges 
which are poured out in the course of the disease being as abundant 
as those of eczema, with the addition of their purulent character, the 
crusts are remarkable for their thickness. They are of a yellowish 
and brownish-yellow color, and have been compared to dried honey, 
the disease itself, in consequence of this similitude, being termed meli- 
tagra. Another point of resemblance between impetigo figurata capitis 
and eczema impetiginodes is the strong odor of valerianic acid exhaled 
by the purulent and semi-purulent secretion. 

Impetigo figurata is usually met with in young persons and children, 
particularly infants at the breast, hence the term impetigo lactantium. 
Then, when the thick crust forms upon the head, the term tinea lactea 
is applied to this affection, as well as to its congener, eczema impeti- 
ginodes. On the face, for the same reason, it constitutes a crusta lactea 
and porrigo larvalis ; and it would be difficult for the most experienced 
dermatologist to determine, in an established case of crusta lactea, 
whether the disease had commenced as a crop of pustules or of 
vesicles. Subsequently, the discharges are exactly the same, the dif- 
ferences, if any, being simply a plus or minus in the proportion of 
pus globules entering into the composition of the morbid secretion. 
This admixture of the pus of impetigo with the ichorous and viscous 
secretion of eczema, gives a milky opacity to the fluid, suggestive of 
a mucous, or rather of a muco-purulent, secretion ; hence the term 
employed by Alibert to designate this character, namely, tinea mucosa. 
In like manner, tinea granulata, another term originating with Alibert, 
has been applied to impetigo, as well as to eczema ; deriving its origin 
from the broken crusts which are scattered among the hair in impetigo 
capitis, and more particularly in impetigo sparsa capitis. 

When impetigo figurata capitis attacks the hairy scalp, it gives rise, 
by its secretions and crusts, and by the disorder and matting of the 
hair which ensue, to all the distress and suffering which have been 
described in association with eczema impetiginodes of the same 
region ; so, in impetigo faciei, the symptoms are the same as in crusta 



IMPETIGINOUS OR PUSTULAR ERUPTIONS. 217 

lactea from eczema. In a case of this disease, delineated in my 
Portraits of Diseases of the Skin, 1 the crust upon the face was so thick 
as to retain the features in a fixed position, and the surface so tender, 
that the slightest touch produced pain. The disease, having extended 
to the ears and back of the neck, prevented the patient from lying 
down in bed; and an accidental pressure of any kind, even the 
motion necessary to open the mouth, occasioned a cracking of the 
skin, and an oozing of blood from the cracks; to which was added 
a constant pricking and itching pain, and a feeling of excessive heat. 

Impetigo sparsa is not unfrequently met with on the scalp (Plate 
X., D e), where it occurs as single pustules or in small groups. These 
individually run through the course already described as appertaining 
to impetigo figurata, forming crusts of various size and various 
degrees of thickness. They are attended with heat, itching, and 
sometimes pain ; are often very tender, and when the crusts are 
removed, are found to be excoriated and moist, from the oozing of a 
semi-purulent secretion. At the decline of the disease the crusts are 
broken up, and the fragments, mingled among the hair, or strung like 
beads on separate hairs, present the characters which have been dis- 
tinguished as tinea granulata. 

Impetigo rarely does any injury to the roots of the hair, and it is 
only in very severe or neglected cases that partial alopecia can occur. 

Diagnosis. — The pathognomonic characters of impetigo are, the 
small size and little elevation of its psydracious pustules ; the subse- 
quent abundant viscous and yellowish secretion which the exposed 
surfaces pour out; and the thick, yellowish-green, or brownish and 
grayish semi-transparent crusts. 

When impetigo affects the chin only, it may be mistaken for 
sycosis, unless we recollect that in the latter eruption the pustules are 
larger, more prominent, discrete, less yellow in color, and succeeded 
by less secretion. Moreover the crusts of sycosis are darker in color, 
less moistened by secretion, not renewed when they fall off, and 
accompanied by tubercles and indurations. 

Causes. — Impetigo occurs in both sexes, at every age, and in all 
seasons; it is, however, more common in children than in the adult, 
and in women and persons having a thin and delicate skin, than in 
the male sex, and those whose skin is less susceptible. 

The disease is referable to constitutional causes, and is commonly 
found associated with the general disturbance produced by den+ition, 
amenorrhoca, or the cessation of the menstrual period. Its appearance 
seems influenced, also, by mental excitement, excess in diet, or 
stimulating drinks, violent exercise, &c. It is commonly met with in 
workhouses, where a number of children of unhealthy constitution, 
poorly fed, and insufficiently clothed, are assembled together; and 
particularly where care is not bestowed upon the three great hygienic 
principles, ventilation, cleanliness, and exercise. 

Local irritation of the skin is an occasional exciting cause, as in 

i Plate VIII., AR. 

\ 



218 DISEASES ARISING FROM GENERAL CAUSES. 

that produced by lichen, the application of stimulating substances to 
the cutaneous surface, and the heat of the sun. 

The impetigo capitis et faciei of infants, the crusta lactea, is 
referable to the same causes as eczema infantile, with which it is 
closely allied. 

Prognosis. — Impetigo is a troublesome and offensive disease, but 
by no means dangerous to life. It is frequently tedious, especially 
when injudiciously treated, and, by the improper use of remedial 
means, may be prolonged indefinitely, or be made to assume the 
chronic form, which latter is always obstinate. 

Treatment. — In impetigo, during its inflammatory stage, emollient 
and sedative fomentations and water-dressing are the best local appli- 
cations. When the inflammation is somewhat abated, the eruption 
should be coated with the benzoated ointment of oxide of zinc rubbed 
down with spirits of wine (5j ad 5j)- The ointment is best applied 
with the finger, and in infants, with a small brush; and care should 
be taken to fill all the hollows of the surface, and the crevices of the 
crusts, where they have been allowed to form. This ointment should 
be applied thickly, and repeated morning and night, and as frequently 
during the day as the surface may be disturbed, or the previous layer 
of ointment rubbed off. If discharges are formed, they may be wiped 
off with a soft napkin, and in the same way loosened crusts may be 
removed. No attempt should be made to wash the eruption, as 
washing is always followed by desiccation of the surface and an imme- 
diate increase of local inflammation and suffering. On the same prin- 
ciple lotions of all kinds are mischievous, unless applied over a coating 
of the oxide of zinc ointment. This latter step may be taken at any 
time, as the ointment in no way interferes with the evaporating action 
of cooling lotions applied to the skin, or the soothing and softening 
effect of water-dressing and fomentations. In general this is all the 
local treatment required, but where the surface is too sensitive to bear 
the zinc ointment, and remains so after the use of water-dressing and 
emollient or sedative fomentations, it may be pencilled with a weak 
solution of nitrate of silver in distilled water (gr. ij — vj ad §j). An- 
other useful local remedy of the soothing class, is a liniment of olive 
oil and lime-water, either alone, or with the addition of liquor plumbi 
diacetatis, or the sedative solution of opium, covering the surface after 
its application with a sheet of cotton-wool. 

Id the chronic state of the local disease the nitrate of mercury oint- 
ment,' more or less diluted, is a valuable remedy; or the nitric oxide 
of mercury ointment, or the ammonio-chloride. Another useful oint- 
ment for allaying pruritus as well as restoring the skin to its normal 
state by gentle stimulation, is the juniper tar ointment, diluted or 
strong. With these ointments may be conjoined a moderate amount 
of friction. In extremely obstinate chronic impetigo, the sulphur 
ointment may be found serviceable. 

The constitutional treatment of impetigo requires in the first instance 
attention to the functions of digestion, the removal of all irritant 
matter from the alimentary canal, the suppression of fever or feverish 
symptoms, if they exist, by antiphlogistic means ; and subsequently 



IMPETIGINOUS OE PUSTULAR ERUPTIONS. 219 

the restoration of the general tone of the system. With this view, 
gently purgative medicines, with salines, or alkalies with bitter infu- 
sions or tinctures, should be exhibited, and these should be followed 
by the class of tonics, gentian, quinine, bark, calumba, chirayta, cha- 
momile, quassia, or taraxacum, according to the custom or views of 
the practitioner. With the tonics, alkalies may be continued, if the 
lithic diathesis still remain, or if there be evidence of the rheumatic 
or gouty diathesis. But if the powers of the system be lowered, then 
the mineral acids may be combined with the bitter remedies, either 
the hydrochloric, the nitric, the nitromuriatic, or the sulphuric. 
Again, if anaemia be present, the citrate of quinine and iron, simple 
tincture of the hydrochlorate of iron, or the acetate of iron with nitro- 
muriatic acid, may be administered, according to the judgment of the 
practitioner. 

In the chronic stage of impetigo, the alterative tonic properties of 
arsenic may be required, and then, as in psoriasis following erythema, 
lichen, or eczema, #ny of the arsenical preparations commonly in use 
may be adopted ; Fowler's or De Valan gin's, solution ; the arseniate 
of soda, ammonia, or quinine ; the iodide of arsenic, or in very stub- 
born cases, where the alterative action of mercury and iodine may 
seem to be desirable, in addition to that of arsenic, the liquor hydrio- 
datis hydrargyri et arsenici or Donovan's solution. 

In crusta lactea my treatment is as follows : a calomel purge of one 
or two grains, according to the age of the child, and repeated once or 
twice in the week, or as often as the child may evince feverishness, 
great irritation, restlessness, heaviness, or peevishness ; from two to 
three minims of Fowler's solution given with meals twice or three 
times a day ; and the constant and efficient application of the benzoated 
ointment of oxide of zinc with spirits of wine. These means properly 
used, I have never known to fail, and I believe never can fail. As 
there is always some anaemia in children affected with this disease, I 
usually combine the Fowler's solution with a few drops of vinum 
ferri ; sometimes I prefer the solution of De Valangin, in which case 
the tincture of the hydrochlorate of iron is the best associate for the 
arsenic ; and sometimes I give the preference to the arseniate of soda, 
on account of its great convenience as a medicine for infants. It is, 
moreover, necessary, in this disease of mal-assimilation and mal-nutri- 
tion, to secure to the child a wholesome diet, and to add to its ordi- 
nary food beef-tea or mutton-tea. It is, perhaps, hardly necessary to 
remark, that the arsenic, which usually agrees remarkably well with 
infants, and with them is an invaluable remedy, should be watched, 
lest it disagree ; and immediately it does so, omitted, and a calomel 
powder <_nvcn. 

In imj)eticjo of the scalp, it may be necessary to shorten and thin the 
hair; but where attention has been bestowed to cleanliness, and the 
head kept well brushed and anointed, I have rarely found it necessary 
to shave or even crop the hair. 



220 DISEASES ARISING FROxM GENERAL CAUSES. 



ECTHYMA. 
Syn. Uepyesis ecthyma, Mason Good. Phlyzacia. Papulous scall. 

Ecthyma 1 (Plate X., H — q) is an acute inflammation of the skin, 
characterized by the eruption of prominent pustules, of a rounded form 
and considerable size, upon any part of the surface of the body. The 
pustules are discrete and scattered, they are developed on a hard and 
inflamed base, and terminate in dark-colored crusts, which leave a 
deeply congested surface, and often a brown stain, at their fall, and 
sometimes a superficial ulcer, followed by a cicatrix. The eruption is, 
for the most part, partial and successive ; in rare instances it is gene- 
ral; in the former case it may endure for one or two weeks, in the lat- 
ter for several months. It is not contagious. 

Ecthyma is endowed by Willan with four varieties, having relation . 
to the constitution and age of the patient ; these are, ecthyma vulgare, 
ecthyma infantile, ecthyma luridum, and ecthym^a cachecticum. I 
prefer, however, with Rayer, to consider the disease as presenting an 
acute and a chronic type ; the former of these divisions corresponding 
with the ecthyma vulgare, and the latter embracing the three remain- 
ing varieties. In a tabular form, the varieties of ecthyma are, 

Ecthyma acutum, seu vulgare, 

{E. infantile, 
E. luridum, 
E. cachecticum. 

ECTHYMA ACUTUM, SEU VULGARE. 

This eruption (Plate X., H — n) is most frequently seen upon the 
extremities, often on the shoulders and neck, but rarely on the scalp. 
Its development is indicated by the appearance of small, red, and cir- 
cumscribed spots,' which gradually rise above the surface, are hard 
and painful to the touch, and increase to a variable size. Upon the 
summit of each of these conical elevations a small quantity of puriform 
fluid is effused beneath the epidermis, and the matter continues to be 
augmented by additional secretion, until .a pustule is formed. The 
size of the pustule is various ; usually it is as large as the half of a 
pea, and surrounded by a hardened base of vivid redness, while at 
Other times it covers the whole extent of the hardened base, and re- 
sembles a bulla distended with pus. The development and growth of 
(lie pustule are accompanied by severe and often lancinating pain. 
In the course of three or four days after the completion of the pustule, 
the contained fluid dries up into a dark-colored scab of various thick- 
ness, which falls off in eight or ten days, leaving behind a congested 
circular spot of a deep red color. Sometimes the purulent fluid is 
removed by absorption, and the surface of the skin is restored to its 
natural state, after repeated desquamation. At other times a super- 

' Der. tx6tjf<v, to burst forth. " Apertum est ah ix.bittv. quod est ticp/uav, id est, erumpere, 
derivatum essej iKbi/uuei, id est, pupulis. nomen in iis quae sponte extuherant in cute." — 
Hippocrates, lih. iii. sec. 01. 



IMPETIGINOUS OR PUSTULAR ERUPTIONS. 221 

ficial ulcer is formed, particuarly on the lower extremities, and ter- 
minates with a slight cicatrix. When the eruption of pustules has 
been numerous, the congested spots left by the fall of the crusts pre- 
sent a remarkable appearance. 

Rayer gives so excellent an account of the structure of the pustules, 
during their progressive development, that I am tempted to quote his 
words. " We find," writes this author, 1 " 1. That in their first stage (red 
elevations) there is merely sanguineous injection, with conical tume- 
faction of the corion ; 2. That in the apex, more rarely over the whole 
surface of the elevations, and under the cuticle, there is an effusion of 
a certain quantity of purulent serum ; 3. That in the third stage, which 
follows immediately after, there is a kind of pseudo-membranous mat- 
ter deposited in the centre of the elevation, which is now evidently 
perforated ; 4. That after the voidance of this matter, and the removal 
of the cuticle, the pustule appears under the form of a cup-shaped 
cavity, surrounded by a hard, thick, puffed edge ; 5. Lastly, that on 
the following days, this thickened margin subsides, at the same time 
that a slight cicatrix is formed under the crust, the centre of which is 
fixed within the point where the perforation had been observed." 

ECTHYMA CHRONICUM. 

Chronic ecthyma (Plate X., h — q) is a more common form of dis- 
ease than the acute variety ; it occurs in successive eruptions, ge- 
nerally in persons of debilitated and cachectic habit, and is prolonged 
for several months. 

When it appears in ill-fed, ill- clad, and weakly children, or in those 
who are debilitated from preceding disease, it constitutes that variety 
which has been designated by Willan, ecthyma infantile. This erup- 
tion is not unfrequently associated with irritation or disease of the 
alimentary mucous membrane. The pustules are very dissimilar in 
point of size, some being small, and some large; they are circular in 
form, surrounded by an areola more or less inflamed, and terminate 
by absorption of the purulent fluid and epidermal desquamation, or 
by ulceration. The ulcers in* this disease are unhealthy, and difficult 
of cure. 

In old persons, and in those whose constitution is injured by excess, 
the congested areolae often present a purplish-red and livid color ; the 
pustules are of large size, and filled with a sanguinolent, puriform 
fluid, and they are remarkable for the tardiness of their course. This 
character of the eruption constitutes the ecthyma luridum (p. Q.) of 
Willan and Bateman. 

In persons of unsound and cachectic constitution, of all ages, the 
cachectic form of eruption is developed. The pustules occur upon all 
parts of the body, but most frequently on the legs. The inflammation 
preceding the eruption is more extensive than in ecthyma acutum, 
and variable in degree. At the end of six or eight days, the epidermis 
is raised by the effusion of a small quantity of dark sanguinolent pus, 

1 Translation by Willis, second edition, p. 530. 



■1-lZ DISEASES ARISING FROM GENERAL CAUSES. 

-which forms, by its increase, an unhealthy and discolored pustule. 
When the pustule is fully developed, the epidermis bursts, and the 
denuded surface becomes covered by a thick, dark-colored crust, which 
remains adherent for several weeks. If the crust be removed by acci- 
dent or design, an ill-favored ulcer, with inflamed edges, is exposed, 
which is tedious and difficult of cure. 

The pustules of ecthyma are not unfrequently associated with sca- 
bies, lichen, prurigo,. and some other chronic affections of the skin. 

Diagnosis. — The large size and prominence of the pustules, their 
inflamed bases, and the mode of their development, serve to distin- 
guish ecthyma from all other pustular affections. When the pustules 
of acne and sycosis attain a large size, they bear some resemblance to 
ecthyma, but are easily distinguished by the broad and inflamed 
areola of the latter, and the hard, tubercle-like elevations without 
areolae of both the former. 

Syphilitic ecthyma is distinguished, from the form at present under 
consideration, by the more chronic character of the eruption, the 
limited extent of the areola, its coppery hue, the blackness and con- 
centric marking of the crust, and chiefly by the presence of other 
signs of constitutional syphilis. 

Causes. — Ecthyma may be developed at all periods of life, and at 
all seasons, but is principally observed in young persons and in the 
adult, and most frequently in the spring and autumn. It is essentially 
a disease of debility and cachexia. 

It may be excited by various stimuli applied to the surface of the 
skin, such as sugar, lime, salt, sulphur, &c. Grocers are liable to this 
eruption, from the irritation produced by the first of these substances, 
and bricklayers of the second. The manipulation of pulverulent 
substances of all kinds is apt to act as an exciting cause, and simple 
friction may give rise to the same consequences. The pustules follow- 
ing the irritation of tartarized antimony are ecthymatous ; they are 
umbilicated, contain in their interior a false membrane, are very 
numerous, and are succeeded by dark-colored crusts. 

Ecthyma is often symptomatic of a disordered state of the system, 
as of some chronic affections of the viscera, or irritation of the gastro- 
intestinal or uterine mucous membrane. It may also be induced by 
excess of mental or physical exertion, by bad and deficient food, want 
of proper clothing, residence in damp and unhealthy localities, want 
of cleanliness, debilitating causes of various kinds, excesses, and expo- 
sure to vicissitudes. 

Prognosis. — The prognosis of ecthyma depends on the state of 
constitution of the patient rather than upon the eruption, which is in 
most cases an effect of disordered health. When the cause is external, 
and the form of the disease acute, the eruption seldom continues 
longer than two or three weeks; but the chronic affection maybe 
prolonged for several months. 

Treatment. — In the acute variety of ecthyma, after the removal of 
the cause, some gentle laxative and alterative medicine, with diluents 
and abstemious regimen, is all that will be required. The best local 
application is the superacetatc of lead, or oxide of zinc ointment, or if 



HERPETIC AND BULLOUS ERUPTIONS. 223 

the inflammation be severe, sedative and emollient fomentations, and 
water-dressing. 

The chronic forms of the disease call for the use of tonics and 
alteratives, of "which the best is the nitro-muriatic acid with gentian. 
Sometimes quinine with sulphuric acid appears to be indicated, or the 
citrate of iron and quinine ; the choice of the form of tonic being a 
matter for the judgment of the medical man. "Where there is ema- 
ciation, particularly in young persons and children, the cod-liver oil 
is an excellent and useful remedy. Arsenic is never called for in 
ecthyma as a specific medicine, but as a general tonic, if thought 
desirable, there can be no objection to its use. 



CHAPTER IX. 

DISEASES ARISING FROM GENERAL CAUSES.. 
HERPETIC AND BULLOUS ERUPTIONS. 

In the four chapters which precede, erythema, lichen, eczema, and 
impetigo follow each other in succession, and are closely allied, not 
only in their general but also in their particular cause. I have 
endeavored to show that they may be regarded as one disease, modi- 
fied by secondary conditions appertaining to the constitution of the 
individual, and that they less frequently occur in a distinct form than 
in combination the one with the other. That erythema is the first 
and the last stage of all ; that lichen is an erythema affecting more 
particularly the follicular structure of the skin ; that eczema differs 
from erythema and lichen only in its pathological effects, being, in 
fact, an erythema or lichen, or both together, with the superaddition 
of an effusion of a colorless ichor or lymph ; and that impetigo is the 
simple substitution of pus for lymph, the natural consequence of a 
pyogenic diathesis. I now, however, come to two diseases, herpes 
and pemphigus, grouped together by an artificial character (namely, 
a large vesicle or bulla), which have nothing in common with the four 
preceding forms of cutaneous disease, excepting their origin in a 
general cause, or one generated in the constitution of the individual; 
and nothing in common with each other, excepting that same general 
cause, and the special pathological phenomenon of the development 
of a vesicle of a more considerable size and more distinct outline than 
the vesicle of eczema, a vesicle which ranges in magnitude from the 
size of a millet-seed to that of a large orange, and has received in 
consequence the technical name of bulla. 

Viewing herpes and pemphigus side by side, there will be found 
more difference between them than in the corresponding groups 
assembled under the heads of erythema, lichen, eczema, or impetigo. 
These groups include diseases which have a certain and mutual 



224 DISEASES ARISING FROM GENERAL CAUSES. 

affinity with each other, but that cannot be said to be the case 
between herpes and pemphigus ; they differ in their proximate cause, 
and in every feature of their development and progress, excepting 
the one accidental similitude of both being attended with an effusion 
of lymph, to an amount sufficient to lift up the epidermis into a 
vesicle or bleb of considerable size. But, even in this particular, 
there is a marked distinction between them ; the vesicle of herpes 
never exceeds a certain moderate bulk, namely, that of the hemi- 
sphere of a small pea ; but the vesicle or bulla of pemphigus has no 
definite size, being of all dimensions on the same as well as on 
separate individuals. Then the character of the inflammation which 
accompanies them is wholly different : one is specific and severe, the 
other general and slight ; one is remarkable for the pain with which 
it is accompanied, the other is painless ; one runs quickly into sup- 
puration as a part of its nature, and is apt to give rise to ulceration 
of the skin ; the other rarely produces pus, and is quite superficial. 
With a perception of these contrasts before me, it is not without 
compunction that I group together herpes and pemphigus, and I do 
so simply with the view of limiting the number of divisions which 
would otherwise exist, and" by so much complicate a department of 
medicine which it is my wish to render plain. Nevertheless, in my 
own mind, an herpetic eruption and a bullous eruption suggest very 
different ideas. 

Heretofore, founding my notions of classification upon the nature of 
the product of the morbid skin, I had, with other authors, grouped 
herpes with eczema, but I can no longer retain it in that position. 
Herpes is a disease apart from all others, and must stand alone ; all 
that I can do for it is, to place it, as I have, by the side of an affec- 
tion, distinguished like itself in some degree, by the large size of its 
vesicles. Rupia I have transferred to a more proper location, namely, 
among syphilitic eruptions. ** 

HERPES. 

Syn. Tetter. Olophlyctis, Alibert. Dartre, Fran. 

Herpes 1 (Plate IX.) is a non-contagious affection of the skin, 
characterized by the eruption of clusters of globular vesicles upon 
inflamed patches of an irregular or rounded form, and of small extent. 
The eruption rarely presents any remarkable degree of severity; it is 
not usually accompanied with symptoms of constitutional disturbance; 
and it lasts for a brief period only ; rarely longer than two or three 
weeks. Each vesicle runs a course of about ten days, and terminate*! 
either by absorption of its contents, by desiccation without rupture, 
or by rupture and the formation of a thin brownish scab, which speedily 
falls. 

The varieties of herpes derive their designation either from the forn 
and arrangement of the clusters, or from the locality of the affection. 
In reference to their general characters, these varieties admit of a 

1 Der. cpTrtiv, to creep. 



HERPETIC AND BULLOUS ERUPTIONS. 225 

natural division into two groups, a phlyctenoid group, and a circinate 
group. The phlyctenoid group is characterized by the irregularity of 
form and distribution of the clusters ; it is typified by the variety 
herpes phlyctenodes, and embraces all the local forms. The circinate 
group, on the other hand, is remarkable for the circular arrangement 
or form of its clusters; hence, the herpes zoster consists of irregular 
clusters disposed in a circular form around the t trunk of the body ; 
herpes circinatus is characterized by the disposition of individual 
vesicles in the form of a circle ; and herpes iris presents the same 
peculiarity in the form of concentric circles. In a tabular plan, the 
varieties may be thus arranged : 

1. Phlyctenoid group. 2. Circinate group. 

Herpes phlyctenodes, Herpes zoster, 

" labialis, " circinatus, 

" nasalis, " iris. 

" palpebrals, 
" auricularis, 
" prseputialis, 
" pudendalis. 

HERPES PHLYCTENODES. 

Syn. Herpes miliaris. Nirles. Olophlyctis miliaris, Alibert. 

The phlyctenoid variety of herpes (Plate IX., b) presents no regu- 
larity of form or of appearance ; it may show itself upon any part of the 
cutaneous surface, or upon several regions at the same time, but is most 
commonly developed on the upper parts of the body, as the face, neck, 
and arms, and less frequently on the lower extremities. 1 The vesicles 
are globular ; they vary in size from a mere point to the bulk of a 
pea, and are produced in a cluster upon an irregular or rounded patch, 
rarely larger than the palm of the hand. Frequently there are two 
or more of these patches. The eruption usually disappears at the end 
of a week : sometimes, however, it is prolonged by successive erup- 
tions to two, and even to three weeks; the yellowish spot which it 
leaves behind continuing perceptible for as many months. 

The eruption is preceded by a sense of heat, tingling, and smart- 
ing, and upon the portion of skin so affected, numerous minute red 
points are shortly perceptible. On the following day the redness of 
the patch becomes general, and a great number of small globular 
vesicles, of various sizes, and distended with a limpid transparent 
lymph, are developed. During the third day the contents of the vesi- 
cles become turbid and lactescent, with here and there one which is 
sanguinolent ; and on the fourth day some few have a semi-purulent 
appearance. On the third and fourth days, the vesicles begin to shrink, 
and on the succeeding days to form, with their contained secretion, 
thin, brownish, scabs ; these are thrown off by desquamation on the 
tenth or twelfth day, leaving a redness and livor of surface, which dis- 

1 In one instance the eruption occurred on the temple ; and one vesicle was developed 
on the conjunctiva, and gave rise to much redness and inflammation. 

15 



226 DISEASES ARISING FROM GENERAL CAUSES. 

appears only by degrees. The purulent vesicles are not unfrequently 
followed by small superficial ulcerations. 

The local symptoms accompanying the eruption are, itching, prick- 
ing, smarting, and an intense burning heat, with frequently a deep- 
seated pain, all of which symptoms continue for a short time in a miti- 
gated degree after the subsidence of the eruption. Constitutional 
symptoms are rarely present, and, should they exist, are limited to some 
degree of languor, thirst, loss of appetite, and diminished secretions. 

The following is an illustration of the common cause and progress 
of herpes. A boy, fifteen years of age, sat for some time on the grass, 
on Good Friday, April 10th, 1846. The next day he had severe pain 
over the whole of the front part of the right thigh, which was attributed 
to rheumatism. On the evening of Saturday a blush of redness, in 
patches, was apparent on the surface. On Sunday, minute vesicles in 
clusters were perceived here and there upon the red patches. These 
vesicles soon became distended with a transparent and colorless fluid, 
and reached their full size, looking, towards evening, like so many 
pearls. On Monday some of the vesicles were already becoming 
shrivelled, and had a purplish hue, while others, fully distended, pos- 
sessed a rich grape-yellow tint. On Tuesday all the vesicles were on 
the decline, with the exception of a few tardy clusters, which were 
now attaining maturity. On Wednesday, the fourth day of the erup- 
tion, the greater part of the vesicles had dried up into reddish-yellow 
wrinkled scabs. On succeeding days the scabs became gradually 
darker and harder, and were closely imbedded in the skin. By 
Saturday a few only of these scabs remained; and on Sunday, the 
completion of the week, traces only of the existence of the eruption 
remained. 

HERPES LABIALIS. 

Syn. Exanthema labiale. Hydroa febrile, J. Franck. Olophtyctis 
labialis, Alibert. 

Herpes labialis resembles herpes phlyctenodes in every respect, 
with the exception of situation and extent. This eruption is preceded 
by itching, redness, swelling, heat, and painful tension of the lip, 
sometimes affecting the mucous membrane of the prolabium only, at 
other times the integument alone, and again, both the one and the 
other conjointly. The redness extends to a variable distance around 
the mouth, sometimes reaching to the nose, and less frequently to the 
cheeks and chin. On the second day from the appearance of the red- 
ness, and sometimes earlier, several crops of small round vesicles, five 
or six in number, are developed on the inflamed surface. Some of the 
vesicles, by their confluence, unite to form small cellular bullae, of the 
size of a split pea. On the third and fourth days, the lymph of the 
vesicles becomes turbid and lactescent, and subsequently semi-puru- 
lent. On the fifth or sixth day a brownish crust is formed by the 
desiccation of the vesicles and their contents; and on the eighth or 
tenth the crust falls. The formation of a crust may frequently be 
prevented, by carefully opening the vesicles as soon as formed, and by 



HERPETIC AND BULLOUS ERUPTIONS. 227 

the application of a weak solution of sulphate of zinc in rose-water. 
When the crust is interfered with during its formation and removed, 
a hardened scab is produced, which remains adherent for a much longer 
period than the natural crust. Herpes labialis is sometimes associated 
with aphthae of the mouth. 

HERPES PALPEBRALIS, NASALIS, ET AURICULARIS. 

An eruption of globular vesicles identical with those of herpes 
labialis is sometimes developed on the upper eyelid, along the borders 
of the alse of the nose, or in the concha of the ear, in association with 
irritation or inflammation of the mucous membrane of the. eye, nares, 
and external ear. The progress of the eruption is similar to that of 
the preceding affection. 

HERPES PRJEPUTIALIS. 

Like herpes labialis, the present variety may affect either the mucous 
or cutaneous surface alone, or both conjointly. The disease in this 
situation appears under the form of one or more red and well-defined 
patches of about the size of a sixpence, upon which the globular vesi- 
cles of herpes are developed. On the cutaneous surface the vesicles 
pass mildly through their course, the fluid is frequently absorbed, 
either in its serous or semi-purulent state, or they form thin, brownish 
scabs, which desquamate at the end of a week or ten days. 

On the mucous membrane the inflammation accompanying the erup- 
tion is somewhat more severe. The vesicles assume a larger size, be- 
come speedily lactescent and semi-purulent, and terminate in thin 
brownish scabs. These are not unfrequently rubbed off previously to 
their natural desquamation, and leave behind them small excoriated 
surfaces, which might, by inattention, be mistaken for chancre. 

The symptoms accompanying both these forms of eruption, are, 
heat, itching, and often a pricking sensation. The disease is dependent 
for its cause on friction with the dress in persons of great suscepti- 
bility of skin; contact with discharges from the vagina; neglect of 
habits of cleanliness ; and irritation of the genito-urinary mucous 
membrane. Herpes prseputialis sometimes becomes chronic, and is 
then difficult of cure. 

In its excoriated state, as I have before remarked, this eruption offers 
some risk of being mistaken for chancre. But the superficial ulcera- 
tion of herpes, the occurrence usually of several small ulcerations in 
a cluster, and the uniform level of the exposed surface, are characters 
which contrast very strongly with the chronic progress of chancre, its 
thickened and raised edges, and the whitish appearance of its surface 
produced by a false membrane. 

HERPES PUDENDALIS. 

This affection presents all the characters of the preceding varieties ; 
the vesicles appearing on the integument and mucous membrane of 
the labia majora, or upon the internal surface of the vulva. In these 



228 DISEASES ARISING FROM GENERAL CAUSES. 

situations, the eruption is often rendered obstinate by the continuance 
of irritation kept up by morbid secretions from the vagina. 

HERPES ZOSTER. 

Syn. Zona. Zoster. Cingulum. Ignis sacer. Zona ignea. Shingles. 
Der Gurtelausschlag, Feuerg Uriel, Germ. 

Herpes zoster, or shingles 1 (Plate IX., A — f), is especially charac- 
terized by the arrangement of the inflamed patches with their clustered 
vesicles, in the form of a half zone, 2 which extends around some part 
of the trunk of the body, from the middle line in front to the middle 
line behind. The eruption usually occurs at about the middle of the 
trunk. When it is developed higher up, the patches take their course 
across the shoulder, and are frequently prolonged along the arm ; and 
when it is situated in the lumbar region, they occasionally extend to 
the thigh and leg, herpes proserpens. In rare instances, the eruption 
is met with forming a half collar to the neck, or a demi-zone around 
the face or head ; it has also been observed upon one side of the 
scrotum or penis. Herpes zoster occurs indiscriminately on either 
side of the body ; by some authors, it is stated that the eruption appears 
for the most part upon the right side, while others contend that the 
left is most frequently affected ; my own experience corresponds with 
the latter statement. It is an acute disease, lasting from one to three 
or four weeks. 

Herpes zoster, in the manner and course of its eruption, is identical 
with the typical form, herpes phlyctenodes, but more severe in its 
symptoms. The patches by which it appears are of a vivid red color, 
commencing usually at both extremities of the demi-zone, and 
proceeding outwards by successive eruptions, until they constitute, 
by their approximation, an irregular line. The first formed patches 
are larger than those which succeed. They are perfectly distinct 
from each other, being separated, to a greater or less extent, by 
interstices of sound integument. Shortly after the appearance of 
each patch, a number of small white and glistening prominences are 
seen upon it, which speedily assume the form of vesicles, and the 
latter go on increasing in size, until, at the end of three or four days, 
they attain the magnitude of small peas. The vesicles are developed 
in groups, consisting of considerable numbers on each patch ; and in 
some situations they become confluent, and resemble small bullae. 
At their first eruption they are filled with transparent lymph, which 
))<•<•< Hues turbid on the second and third day, and subsequently semi- 
purulent, or purulent in some, and of a purplish or blackish tint in 
others. On the fourth or fifth day, the vesicles begin to collapse and 
fade ; they look wrinkled, and, during the two following days, dry 

1 See " Portraits of Diseases of the' Skin," Plate V., AY. In this figure, besides the zona 
around the trunk of tin- body, a large patch of herpes phlyctenodes is seen on the flank, 
just above the hip. 

* An unfounded notion was prevalent among the older physicians, that if the zone 
encircled the entire body, the case would terminate fatally. Pliny, amongst others, refers 
to this presumption. 



HERPETIC AND BULLOUS ERUPTIONS. 229 

up, with their contents, into small scabs of a dark brown color, which 
fall on the tenth or twelfth day, leaving behind them a redness of the 
skin, which slowly disappears. The vesicles are not unfrequently in- 
termingled with true pustules. 

This disease is greatly modified, as regards its termination, by the 
state of health and vigor of the patient. In young and healthy 
persons the contents of many of the vesicles are absorbed on the 
fifth or sixth day, and the affection terminates by desquamation. In 
weakly and old persons, on the contrary, the sero-pustules burst, and 
produce painful excoriations, or ulcerations, which are often long in 
healing. These unpleasant consequences are most frequent on the 
dorsal region of the trunk, from the friction and pressure to which 
the vesicles are subject in this situation during decubitus. Sometimes, 
also, in old persons, the disease terminates in gangrene of the integu- 
ment. 

The symptoms accompanying herpes zoster are, a pungent and 
burning heat {ignis sacer, zona ignea) at the commencement of the 
vesicular eruption, and a continuance of the burning pain, to a 
greater or less extent, throughout the course of the disease. Its inva- 
sion is not unfrequently indicated by acute pains, which seem to shoot 
through the chest and epigastrium, and by palpitations and tumultu- 
ous action of the heart. The close of the affection is sometimes 
marked by severe, and often intense neuralgic pains, which continue 
for several weeks, or even months. The constitutional symptoms are 
for the most part slight, consisting of feverishness, quickened pulse, 
and gastro-intestinal irritation. In some cases, the latter symptom is 
remarkable for its severity; and, in rare instances, the eruption is pre- 
ceded by a rigor. 

The urinary secretion in herpes zoster has been made the subject of 
chemical examination by Heller. 1 In one case, that of a boy eight 
years of age, the urine was abundant, faintly alkaline, pale yellow, 
rather turbid, rapidly became putrid, and deposited crystals of ammo- 
niaco-magnesian phosphate. Its specific gravity was 1014-1015. In 
a young man, aged nineteen, the urine was clear, became turbid in 
the course of twelve hours, and deposited crystals of ammoniaco-mag- 
nesian phosphate ; specific gravity 1018. In a man, thirty-one years 
of age, in whom there was slight fever, the urinary secretion was sup- 
pressed, that which was examined being the first that had passed for 
twenty-four hours. It was strongly alkaline, and deposited a sediment 
of ammonia co-magnesian phosphate and urate of ammonia. Its specific 
gravity was 1028. 

The deductions resulting from the analysis of these three cases are, 
that there is — " 1. A marked increase of the chlorides and phosphates, 
and a corresponding diminution of the sulphates ; 2. An excess of hy- 
drochlorate of ammonia; 3. A large amount of fat; 4. A diminution in 
the amount of uric acid;" an increase only occurring when the disease 
is accompanied with fever. The presence of oxalate of lime may al- 
ways be suspected in these cases. 

■' Dr. Day, in Simon's Animal Chemistry. 



230 DISEASES ARISING FROM GENERAL CAUSES. 

HERPES CIRCINATUS. 

Syn. Zona herpetica. Vesicular ringworm. 

Herpes circinatus (Plate IX., g) is an eruption of vesicles of small 
size and globular shape, upon patches of inflamed skin, which assume 
the form of a circular ring. The circles are of various size and 
breadth, rarely exceeding in diameter the palm of the hand, and inclose 
an area of unaffected skin. They are of a vivid red color, and the ve- 
sicles numerous and sometimes confluent. The patches run through 
their course in eight or ten days, but when the disease assumes a chro- 
nic character, and the circles are successive in their eruption, it may 
be prolonged for several weeks. This eruption appears upon all parts 
of the body, but is most frequently developed on the face, neck, breast, 
and upper extremities. 

Herpes circinatus commences in the form of small circular or oval 
patches of vivid redness, which become pale in the centre, while they 
increase in size by the circumference. The vesicles are developed 
nearer the outer margin of the patch; they are small and globular, 
and run through the usual course of herpetic vesicles, becoming, at 
first, turbid and milky, and then desiccating into small thin scabs, 
which fall off in eight or ten days, the denuded surface of the skin 
retaining a red color, which gradually subsides. The symptoms ac- 
companying the eruption are, a slight pricking and smarting sensa- 
tion, with some degree of itching. 

When the attack is slight, the vesicles are small, and their contents 
are disposed of by absorption, the eruption terminating by desquama- 
tion. In other cases, the central area is not Avholly free from the in- 
fluence of the inflammatory action, but desquamates with the circum- 
ferential ring. 

HERPES IRIS. 

Syn. Rainbow ringworm. Erythema iris. Pemphigus iris. 

Herpes iris 1 is a very remarkable and comparatively rare variety of 
cutaneous affection. It is characterized by the eruption of a vesicle 
on a small circular erythematous blotch ; the blotch increases in size 
by its periphery, throwing out an erythematous ring upon which the 
cuticle is raised into an annular vesicle more or less complete. 
Sometimes the process ceases at this stage, at other times new rings 
are produced, either with or without fresh elevations of the cuticle, 
and the blotches attain a considerable size. The rings being succes- 
sive, exhibit various tints of color, hence the term iris, and the eleva- 
tions of the cuticle being also successive, either remain as puckered 
rings more or less complete, sometimes as separate vesicles, or they 
are taken into the original vesicle and constitute a bulla of considera- 
ble size (pemphigus iris). On the decline of the eruption the contents 
of the vesicles are absorbed, or dry up, and together with the cuticle 

1 Portraits of Diseases of the Skin, Plate VI., A/, exhibits a well-marked case of this cu- 
rious form of eruption. 



HERPETIC AND BULLOUS ERtUPTIONS. 231 

form a thin laminated scab, which after a time is thrown off: the 
erythematous rings also desquamate, and the site of the blotch remains 
for some days, marked by circular traces of concentric rings, which 
fade by degrees. 

As I have remarked, the eruption may stop at any stage of its 
progress, and on different parts of the body, or in different degrees of 
severity of the disease, the patches are more or less considerable, and 
their characters more or less complete. Thus, if it stop at the erythe- 
matous stage, without throwing up a vesicle, but produce a series of 
rings, the case is one of erythema iris ; if it develop a vesicle of 
moderate size, either surrounded by erythematous rings, or by vesicu- 
lar as well as erythematous rings, the case is herpes iris; and if, by a 
more active effusion, the vesicle should creep on with the erythematous 
rings, taking them into its area as it proceeds, a bulla of greater or 
less magnitude is formed, and the case is pemphigus iris. When the 
eruption is general, the whole of these forms may frequently be seen 
at the same -moment, and the gradations of development are made 
evident. 1 

In elderly persons this eruption is occasionally met with occurring 
on the hands and feet, and remaining at the erythematous stage ;_in 
adults, the herpetic form prevails ; in children, and also in adults 
where the system is relaxed and the constitution cachectic, the bullous 
or pemphigoid form is most frequently met with. In the erythema- 
tous form, as it is commonly seen on the hands, the eruption presents 
three shades of color, which are more or less distinct ; the centre is 
red, then follows a ring of a whitish or yellowish tint, and externally 
to this is a narrow areola of light crimson. On other parts of the 
body, the number of tints of color and the number of rings may be 
increased to five or six, or even double that number. I have observed 
that a new ring is generally produced in the course of twenty-four 
hours ; so that by counting the rings it would be possible to determine 
the number of days it had taken to arrive at its existing state. In 
one patch I counted seven white rings, representing seven days, and 
seven circles of fading red between them, the outermost white ring 
being bounded by a narrow areola of pale crimson ; and in another 
patch, only half an inch in diameter, I counted nine different tints of 
color, which from the centre to the circumference were as follows: red, 
brown, white, deep red, lighter red, deep red, pale red, deep red, yel- 
lowish white, and crimson blush. 

Herpes iris is essentially chronic, and a disease of cachexia, and in 
both these particulars it is allied rather with pemphigus than with 
herpes. Herpes runs a definite course, and although its patches may 
appear in succession, each individual patch has its specific and uniform 
career. Not so with regard to herpes iris; in the erythematous form 
it is always slow, remaining without change for several days, while in 
the bullous form, it has all the rapidity of pemphigus ; and in neither 

1 I)r Marshall Hall has given an excellent description of this disease in the "Edinburgh 
Mpdical and Surgical Journal." He remarks that some of the patches attain the diameter 
of an inch, and that the central vesicule sometimes becomes developed to the size of a 
bulla, and obscures the concentric- rings. 



232 DISEASES ABUSING FROM GENERAL CAUSES. 

has it the exact periods of herpes. The same remarks apply to the 
constitutional symptoms : in the erythematous form, the symptoms 
are referable to chronic mal- assimilation ; while in the bullous form, the 
leading character of the disorder is cachexia. In one patient, a little 
boy, there was a perpetual state of feverishness, with emaciation, and 
a dry and parched state of the skin ; while in another, an adult, the 
mucous membrane, was severely affected ; there were aphthae in the 
mouth, fauces, and nares, the bowels were sometimes teased with 
diarrhoea, sometimes with dysentery, and the discharges from the 
bowels contained a quantity of mucus tinged with blood. The whole 
condition of this patient was one of cachexia, and when the eruption 
broke out, 'the constitutional symptoms were relieved. 

Diagnosis. — The globular form of the vesicles, their size, their 
number, their pearl-like lustre, their clustered arrangement, and the 
redness and isolation of the patches, are the chief pathognomonic 
characters of herpes, and serve to distinguish it from every other 
affection. The vesicles are too small to be mistaken for the bullae of 
pemphigus, and they are larger, more prominent, and better defined 
than the vesicles of eczema. 

Herpes phlyetenodes and zoster are distinguished only by the arrange- 
ment of the inflamed patches. In the former they are distributed 
upon various parts of the body at the same time, while in the latter 
they are limited to a region. The vesicles of herpes zoster are larger 
than those of the other varieties, and are also more violent in their 
effects. 

Herpes circinatus, from the peculiarity of its form, is liable to be 
confounded with erythema circinatum, or with lepra in its decline. 
From the first it is not easily distinguished, unless one or more of its 
vesicles remain ; from the second, the absence of a hard and elevated 
border, the absence of similar patches on other parts of the body, the 
presence of, at least, one or two herpetic vesicles, and the speedy de- 
cline of the redness, serve to establish a difference. 

Herpes iris, in its erythematous stage, bears some resemblance to a 
variety of roseola with concentric rings. 

Causes. — Herpes must be regarded as a neurotic affection, as origi- 
nating in some cause which weakens the tone and vigor of a nerve or 
its cutaneous branches, and renders the part of the skin which it sup- 
plies more sensitive to the influence of an irritant, as of a cold wind. 

This seems to be especially the case in herpes zoster, in which the 
neurotic affection, as indicated by neuralgia, precedes the eruption of 
the skin, and in which also the neurotic affection not unfrequently 
continues after the eruption is healed. Herpes occurs, for the most 
part, in young persons and females, and particularly in those who 
possess a delicate and irritable skin. The seasons in which the disease 
is most prevalent are, the spring, the summer, and the autumn. 
Herpes is very commonly dependent upon some disturbance of the 
digestive functions, or upon irritation of the respiratory mucous mem- 
brane, and may frequently be regarded as an effort of the system to 
eliminate some disposition to visceral disease. The ordinary exciting 



HERPETIC AND BULLOUS ERUPTIONS. 233 

causes of the affection are, irregularities in diet, exposure to cold 
while the body is heated, coldness and dampness of the atmosphere, 
a cold east or northeast wind, contact of local irritants, fatigue, moral 
emotions of a depressing kind, &c. 

Herpes labialis not unfrequently results from the influence of cold, 
as in the transition from a warm atmosphere to a cold sharp wind. It 
is also associated with gastro-pulmonary irritation, and frequently 
appears as a critical sequela of fevers, catarrhs, and some affections of 
the viscera. 

Herpes zoster frequently attacks adults and old persons, and in the 
latter is often a painful and distressing disease. In adults it has been 
observed to be more common in the male than in the female sex. 
The seasons most favorable to its appearance are the spring and 
autumn. Sometimes the affection would appear to be hereditary, and 
in certain seasons it has 1 attacked so many persons as to have the 
character of an epidemic. In rare instances it has been observed as 
a critical eruption. I regard cold as its special cause. 

Herpes circinatus is sometimes seen to attack several members of 
the same family at the same time, or consecutively. This observation, 
however, merely points to a similarity of exciting cause, since various 
experiments have shown the impossibility of propagating the eruption 
by inoculation. 

Prognosis. — Herpes, in young persons and in the adult, is a mild 
disease, and is important only in relation to the visceral affections 
with which it may be concomitant, and of which it is frequently symp- 
tomatic ; in old persons, however, it is more serious, from a disposition 
to gangrene of the inflamed skin, and especially to neuralgia. 

Treatment. — The treatment of herpes should be mildly antiphlo- 
gistic, and should consist of gentle laxatives, diaphoretics, and diluents, 
unless some visceral disorder be suspected, and call for especial atten- 
tion. The local management requires the aid of fomentations and 
emollients to relieve the local pain, unless contraindicated by position 
or other circumstances. In most instances a simple ointment will be 
found preferable to fomentations, especially when the vesicles are 
seated on parts of the body liable to friction or pressure. In the 
latter case, where some of the vesicles have burst, and the surface is 
bedewed with moisture, it should be dusted with starch powder. 

The severe pains which often accompany herpes zoster, sometimes 
preceding and sometimes following it, and evidently neuralgic, should 
be treated with colchicum and iodide of potassium, followed by qui- 
nine ; and the local suffering at the same time combated by sedatives. 
In three cases of this kind I found tincture of opium with tincture of 
aconite, rubbed into the painful part, procure relief; but in other cases 
the remedy has failed. Nothing can be conceived more dreadful than 
the pangs accompanying herpes sometimes become: a gentleman whom 
I once asked to give me an idea in words of the nature of his suffer- 
ing, replied, "You must fancy the marrow taken out of the bones of 
my arm, and a rough towel threaded through them; you must then 
imagine two devils at work with all their strength at each end of the 
towel, sawing it backwards and forwards ; that is what it is like." In 



234 DISEASES ARISING FROM GENERAL CAUSES. 

the region of the scapula, around the thorax and around the abdomen, 
the pain is sometimes dreadfully severe. Dr. Ranking, in his " Ab- 
stract," records the opinions of two gentlemen, Dr. Palmer and Mr. 
Humpage, on the local treatment of this painful affection ; the former 
recommends the application of the tincture of arnica, and the internal 
use of the oxide of silver; the latter proposes a blister followed by a 
belladonna plaster. Dr. Ranking himself suggests the endermic use of 
morphine or electro-magnetism. 

Herpes labialis is too slight to require remedial treatment ; if, how- 
ever, the heat, tension, and itching, are productive of much uneasiness, 
they may be relieved by a weak lotion of acetate of lead, or sulphate 
of zinc ; by an ointment containing a drachm of the liquor plumbi 
diacetatis to an ounce of elder-flower ointment ; or by the benzoated 
ointment of oxide of zinc. 

The course of the vesicles, at an early stage, may frequently be 
arrested by the above lotions ; when, however, the vesicles have 
formed, they may still be checked by puncturing them with a needle, 
and inserting into the puncture, for an instant, a fine point of nitrate 
of silver. 

The other local forms of herpes, including herpes pneputialis, may 
be treated upon the principle recommended for herpes labialis. 

In herpes zoster, when the patient is weakly or aged, tonic remedies 
and a generous diet will be required. He should be careful not to lie 
on the affected side, lest the vesicles be ruptured, and troublesome 
ulcerations or gangrenous sores ensue. 

When the vesicles are succeeded by excoriations or ulcerations, the 
ointments recommended for herpes labialis, spread upon lint, will be 
found useful. If the excoriations exhibit a tendency to gangrene, an 
ointment of nitrate of silver, containing ten grains of the salt to an 
ounce of simple cerate, should be used. And if the disease be accom- 
panied with much pain, an ointment of opium, in the proportion of 
half a drachm of the watery extract to an ounce of simple cerate, will 
be found an advantageous remedy. My friend, Mr. Lay, who suffered 
severely from the smarting and itching attendant upon this disorder, 
while engaged in Beechey's expedition, had recourse to a moist cloth, 
which he found of great service in quieting those symptoms when 
they had become unbearable from the warmth of bed. Lotions of 
sulphate of zinc, of super-sulphate of alumina, and borate of soda, are 
recommended by Bateman for the same purpose. 

The ectrotic treatment by caustic is applicable to herpes zoster, as 
well as to herpes labialis, and other varieties of the eruption. The 
vesicles should be carefully punctured with a needle, and the sharp 
point of a pencil of nitrate of silver introduced, for an instant, into the 
opening. By this means the progress of the vesicles may be checked, 
and the cure brought more speedily about than by leaving the eruption 
to its course. 

If any tardiness be apparent in the development of the eruption, 
the treatment suggested by Mr. Plumbe should be adopted ; namely, 
the application of a strip of blistering plaster on the sound skin, in the 
situation where the vesicles are likely to appear, or immediately ad- 



HERPETIC AND BULLOUS ERUPTIONS. 235 

joining those which are already produced. This has not only the effect 
of checking the extension of the disease, " but of producing a shrivel- 
ling of the vesicles already formed, and cutting short its progress alto- 
gether ; avoiding at once its tediousness and all the pain attending it." 
Care must be taken not to apply the blister over the vesicles, lest it 
occasion sloughing of the derma. Moreover, Mr. Plumbe has re- 
marked, that blisters do not rise upon the inflamed patch of herpes. 

Herpes circinatas and ins require no special remedies; they should 
be treated upon the general principles above indicated, and by tonic 
medicines and regimen. When the circinate variety becomes chronic, 
Gibert recommends an ointment composed of one drachm of sulphuret 
of lime, fifteen grains of camphor, in powder, and one ounce of lard. 
If this ointment should fail, a blister will often succeed in putting a 
stop to the eruption. 

PEMPHIGUS. 

Syn. Pompholyx. PempMx. Fievre bulleuse, Fran. Blasenausschlag ; 
Wassenblasen, Germ. PempMx, Alibert. 

Pemphigus 1 (Plate VIII.) is an eruption of bullae of considerable 
size, appearing upon circular or oval erythematous patches corres- 
ponding in diameter with, or a very little larger than, the bases of 
the bullae. The bullae arise in the course of a few hours ; they vary 
in bulk from that of a split pea to that of one valve of a walnut- 
shell, and occasionally they increase to the size of a fowl's egg. On 
their first appearance they contain a transparent, limpid, or yellowish 
serum, which, in a short space of time, becomes pinkish, sanguineous, 
or turbid, and is eventually discharged by the rupture of the bulla, 
or desiccates into a thin, dark-colored crust. When the bulla bursts, 
which it generally does in one or two days, an excoriation corres- 
ponding with its base remains behind. The disease occurs usually 
in successive crops ; in rare instances, only, simultaneously upon all 
parts of the body. It may be partial or general, and may be pro- 
longed in duration from a few days to several months, and even years. 

The numerous varieties 2 of pemphigus indicated by different 
authors may all be embraced under the three heads of acute, chronic, 
and gangrenous. The first includes the pemphigus vulgaris, pom- 
pholyx benignus, and pompholyx solitarius of Willan ; the second 
corresponds with the pompholyx diutinus of that author; while the 
third is the pemphigus infantilis of Willan, the pemphigus gangre- 
nosa of Stokes. The pemphigus contagiosus of Willan appears to 
be based upon insufficient data. 

PEMPHIGUS ACUTUS. 

Syn. Pompholyx. Pemphigus vulgaris ; confluens ; confertus. 
Pemphigus acutus 3 (Plate VIII.), is a rare form of cutaneous disease, 

1 Der. Tri/uipi^ a bubble ; iro/uqtwg, a water-bubble. 

2 Pemphigus congenjtus; p. infantilis; p. simultaneus ; p. successivus; p. solitarius; p. 
confluens; p acutus; p chronicas; p pyreticus; p. apyreticus. 

8 Portraits of Diseases of the Skin, Plate VIII», AG. 



236 DISEASES ARISING FROM GENERAL CAUSES. 

attacking children and young persons chiefly, attended with a trifling 
or moderate degree of constitutional disturbance, and lasting for a 
longer or shorter period. 1 The disease may be partial or general, 
disseminated or confluent, and it occurs for the most part in successive 
eruptions. 

The constitutional symptoms of acute pemphigus may be slight, 
not exceeding a trifling degree of listlessness or languor, or they may 
be severe, consisting of chilliness and rigors, flushes of heat, pains in 
the head and limbs, thirst, loss of appetite, nausea, sore throat, pain 
at the epigastrium, quick frequent pulse, and sometimes delirium. 
Irritation of the gastro-pulmonary, or of the urethro-sexual mucous 
membrane, is a frequent complication of the constitutional symptoms. 

The milder series of the above detailed symptoms belong to the 
pompholyx benignus of Willan ; the same mild constitutional affection, 
with sickness and languor, accompanies his pompltolyx solita?-ius. 

The local symptoms consist in the appearance, on the second or 
third day, or at a later period from the commencement of the consti- 
tutional disorder, of small red spots, accompanied by itching and a 
dry burning sensation. The spots speedily increase in size, and con- 
stitute circular erythematous patches, which vary in their degree of 
redness from a pale to a vivid tint. In the course of a few hours a 
vesicle rises in the middle of each patch, becomes rapidly distended 
with a limpid serum, and increases to the size of a hazel-nut, or large 
walnut. The bulla is of a circular or oval form, and frequently some- 
what flattened at its summit. It usually corresponds in diameter with 
the breadth of the erythematous patch, which it then completely 
conceals; at other times it is somewhat smaller than the patch, and 
the latter shows around it as a narrow zone. Sometimes, again, the 
bulla is much smaller, and appears to be surrounded by a broad areola. 
The bullae generally burst at the end of a day or two, and expose an 
excoriated surface, which secretes a serous fluid for a few days longer, 
and then becomes covered by a thin, yellowish scab, which gradually 
assumes a brown, and subsequently a black color. When the rupture 
of the bullae does not take place, the limpid and transparent fluid 
which they contain assumes a yellowish and amber tint; it then be- 
comes turbid and opaque, diminishes in quantity by absorption and 
evaporation, and at the end of about a week, dries up, forming a thin 
dark-colored scab. Occasionally the contents of the bullae become 
pinkish or purplish in place of yellowish and turbid; and, when the 
local, inflammation has been violent, they may even be mingled with 
lymph or pus. The scabs fall in the course of three weeks, leaving 
the skin beneath of a dusky red hue, but perfectly sound. The period 
of rupture of the bullae is dependent in great measure upon situation, 
and upon the greater thickness or thinness of the epidermis. The 
bullae present some variety in point of distribution ; they are some- 
times isolated ; sometimes aggregated into clusters or confluent ; and 
sometimes are disposed in circles around the circumference of a given 

1 Rayer relates a remarkable and interesting ease of this affection, which was ad- 
mitted into hospital on the 21st of August, and discharged cured on the 3d of Sep- 
tember, 



HERPETIC AND BULLOUS ERUPTIONS. 237 

patch of erythema. The duration of the disease is regulated by the 
manner of its irruption ; -when the bullae appear at once, the affection 
terminates in one or two weeks. When, however, they are developed, 
as usually happens, at successive periods, the disease is prolonged in a 
similar ratio, and may extend to three weeks or a month. In the 
progress of the cutaneous eruption vesicles are not unfrequently 
observed upon the mucous membrane of the mouth. 

The fluid of pemphigus has been made the subject of chemical 
analysis by Scherer. 1 It had a yellowish tint, an acid reaction, a 
specific gravity of 1018, and deposited a sediment composed of corpus- 
cles, which Scherer states to have resembled mucus or pus-corpuscles, 
but which were probably newly-formed epidermal cells. On evapora- 
tion it gave forth an odor of acetic acid, and deposited a quantity of 
very white albumen on being heated. It contained no trace of urea. 
The analysis gave the following results : 

Water, 940.0 

Solid constituents, . 60.0 

Fat containing cholesterin, ....... 2.6 

Albumen, with earthy phosphates, ..... 48.0 

Alcohol extract, with lactate of soda, and chiorides of sodium 
and potassium, ........ 6.5 

A substance resembling ptyalin, soluble in water, . . 1.9 
Free acetic acid and corpuscles. 

In the same patient, five years afterwards, the proportions of water 
and solid constituents were 959.8, 40.2. 

In certain vesicles on the abdomen, probably herpetic, from the 
quantity of albumen which they contained, the fluid contents, exa- 
mined by Girardin, gave the following analysis : 

Water, . 939.500 

Solid constituents, 60.500 

Albumen, . 49.200 

Cholesterin, 6.475 

Alcohol extract, . 1.075 

Phosphates of soda and lime, and chloride of sodium, 3.750 

The urine analyzed by Heller, in a case of severe pemphigus, which 
proved fatal, the patient being a woman forty years of age, was acid, 
and its specific gravity 1017.5. It deposited a light cloudy sediment 
of mucus with fat-globules, urate of ammonia, and epithelium scales. 
His analysis is as follows : 

Water, 955.80 

Solid constituents, 44.20 

Urea, 24.63 

Uric acid, 0.58 

Extractive matters, 11.79 

Fixed salts, 7.20 

" Of the fixed salts the earthy phosphates were normal, the sulphates 
much increased, and the chloride of sodium proportionally diminished. 
The urea is considerably above the normal average." 2 

1 Dr. Day, in Simon's Animal Chemistry. 2 Ibid. 



238 DISEASES ARISING FROM GENERAL CAUSES. 

In the case of a little boj, affected 'with acute pemphigus, iny 
brother, Dr. Marris Wilson, found the quantity of urine passed in the 
twenty-four hours much below the average, namely, about twelve 
ounces; its specific gravity high, namely, 1033; and its reaction 
powerfully acid. It was of a light color, deposited on standing a light 
flocculent cloud containing minute crystals of oxalate of lime, and was 
loaded with urea. In a thousand parts the quantity of solid constitu- 
ents was 7G.89. 1 

In the exceedingly rare variety of pemphigus named by Willan 
pompholyx solitarius, the bulla attains the size of an orange, enlarging 
very rapidly, and containing several ounces of serous fluid. It is pre- 
ceded by a disagreeable sensation of tingling and smarting, breaks in 
about forty-eight hours, and is succeeded by a superficial ulceration. 
At the end of one or two days after the disappearance of the first 
bulla, another rises in its vicinity, and pursues the same course as the 
preceding. In this way five or six bullae may follow each other suc- 
cessively, extending the duration of the disease to eight or ten days. 
Willan remarks, with regard to pompholyx solitarius, that "it is a 
disease which rarely occurs, and seems only to affect women. I have 
seen three cases of it : in one, the left arm was affected ; in the other 
two the breasts. The excoriations occasioned pain and irritation, with 
partial hardness in the substance of the breasts." Biett met with a 
chronic variety of this disease. 

PEMPHIGUS CHRONICUS. 
Pompholyx diutinus, Willan. 

The chronic form of pemphigus is identical with the pompholyx 
diutinus of Willan. It is of more frequent occurrence than the acute 
variety, is tedious and painful in its course, always successive in its 
appearance, and takes place in persons of debilitated constitution of 
both sexes, and in aged individuals. In its eruption it is either 
general or partial, and occasionally it makes its attacks at a particular 
season, for several consecutive years, appearing, for instance, in the 
autumn or winter, and declining in the spring. Sometimes it lasts 
continuously for years. 2 

The constitutional symptoms are slight as compared with pem- 
phigus acutus. There is usually some degree of sickness of stomach, 
headache, and lassitude, which precede for several days the appear- 
ance of the eruption. And if the latter be severe, the constitutional 
symptoms are considerably augmented. The cutaneous disease is 
sometimes associated with aphthae, with considerable gastro-intestinal 
irritation, with dysuria and hematuria, and in old persons it not 
anfrequently terminates fatally in consequence of its complication 
with pulmonary disease, or with effusion into the serous cavities. 

1 For the details of this ease see Portraits ol Diseases <>t' tin- Skin ; pemphigus acutus, 
Plate VII.. AC 

2 Dr. Ducbesne-Duparc relates that he saw, in St. Louis, a girl eighteen years of age of 
weakly constitution, who had never menstruated, and who had been affected with chronic 
pemphigus since the age of live years. 



HERPETIC AND BULLOUS ERUPTIONS. 239. 

The local symptoms are ushered in with pricking and smarting of 
the skin, and by the eruption of a number of small reddish spots, upon 
■which bullae speedily appear. The bullae increase in the course of a 
few hours to the size of a pea or walnut, and sometimes attain the 
magnitude of a fowl's egg. At the end of three or four days some of 
the bullae burst, and discharge their contents, leaving behind them an 
angry-looking excoriation of the derma. In others the serous fluid 
becomes reddish and turbid, and decreases in quantity until it dries 
up, forming a dark-colored scab, covered with the shrivelled epidermis. 
As one crop disappears another is produced, so that the disease may 
be observed in all its stages at the same moment, and may be prolonged 
for several months, or with intervals for years. Occasionally the bullae 
are confluent, especially when they make their appearance, which is 
not frequently the case, on the face. 

Chronic pemphigus is sometimes complicated with prurigo, particu- 
larly in old persons; this complication excites the most distressing irri- 
tation, and frequently causes a fatal termination. 

PEMPHIGUS GANGRiENOSUS. 

Syn. Pemphigus infantilis, Willan. Rupia escharotica. 

This disease consists in the formation of bullae upon somewhat 
prominent and purplish or livid spots. The bullae are smaller than 
in the preceding varieties ; they a.re irregular in form, and flattened at 
the summit, and they contain a sanguinolent serous fluid, which be- 
comes turbid and dark-colored, or almost black. At this period, the 
bullae are surrounded by a purplish areola, formed by the circum- 
ference of the livid spot upon which they are developed. At a 
variable period after their distension the bullae burst, and leave at 
their bases unhealthy and excavated ulcers, which increase gradually 
in breadth and depth. The ulcers are painful ; they are frequently 
covered with sloughs, they secrete a sanious and fetid pus, their 
borders are thin and inflamed, and they are slow and tedious in their 
cure. As soon as the ulcers have formed, other bullae arise, and 
follow the same course with the preceding, and the disease generally 
terminates in the death of the patient, from excessive and continued 
irritation. This disease occurs chiefly on the lower extremities, on 
the trunk of the body, more particularly its anterior surface, on the 
neck, and on the scrotum or labia pudendi. It is accompanied with 
fever, sleeplessness, restlessness, and general disturbance of the nutri- 
tive functions. 

Dr. Whitley Stokes, in a paper published in the Dublin Medical 
Edsays for 1807, describes this disease as it makes its appearance in 
;ui epidemic form among children in Ireland, under the name of pem- 
phigus gangrsenosus. It is known in different counties of Ireland 
under the names of white blisters, eating hive, and burnt holes. Some- 
times the eruption is preceded by a livid suffusion of the skin : more 
frequently, in a state of perfect health, one or more vesicles somewhat 
larger than a small-pox pustule appeal-, increase for two or three days, 
burst, and discharge a thin fluid having a disagreeable smell, limpid 



240 DISEASES ARISING FROM GENERAL CAUSES. 

in most cases, sometimes whitish and sometimes yellowish. The sore 
left by the breaking of the vesicles is painful, discharges a thin, fetid, 
ichorous fluid, ulcerates and spreads quickly, the edges of the ulcer 
being livid. The unfavorable signs of the disease are the rapidity of 
extension of the sores, their abundant and highly fetid discharge, and 
the blackness which commences at the edges and spreads over the 
entire sore. 

The parts chiefly attacked are the fold of the ears, the hands or feet, 
generative organs, breast, groins, abdomen, and inside of the mouth 
and lips. " If the sores are behind the ears, they destroy the connec- 
tion of the posterior' cartilage with the cranium ; they spread to the 
meatus auditorius ; to the eyes, the sight of which seemed, in a few 
cases, to have been destroyed one or two days before death; and they 
sometimes extend to the vertex. 

" The constitutional disturbance that accompanies this disease 
seems principally the effect of irritation. When the vesicles burst, 
the child begins to grow peevish and fretful, pale, loses its appetite, 
and the flesh becomes remarkably flabby. The periods of the disor- 
der are not very regular ; but it often happens about the eighth day 
that the pulse sinks, the lividity spreads over the whole sore, the fetor 
and discharge increase greatly." " Death takes place about the tenth 
or twelfth day, often preceded by convulsions, sometimes by extreme 
lividity." 

Pemphigus contagiosus, — Willan founds a contagious variety of 
pemphigus upon the description of an endemic disease, accompanied 
with bullae, which raged in Switzerland in 1752, and which is recorded 
by Dr. Langhans. He also alludes, in support of this variety, to the 
bullae of plague, and to those which are sometimes observed in the last 
stage of typhus fever. The contagious variety is far from being satis- 
factorily established. 

Diagnosis. — Acute pemphigus, with its bullae raised upon inflamed 
bases, bears some resemblance to erysipelas; but the number and small 
size of the erythematous patches of the former are easily distinguished 
from the extensively inflamed, the tumefied and painful surfaces pre- 
sent oil by erysipelas. The duration of the disease, with the exceeding 
mildness of the constitutional symptoms, are the principal character- 
istics of the chronic form of pemphigus. 

Causes. — Acute pemphigus attacks children and young persons 
chiefly ; occasionally it appears as a congenital affection, and is some- 
times of hereditary origin. The season during which it is most pre- 
valent is the summer. Its occasional causes are teething, gastric and 
intestinal irritation, excess *in diet, deficient innervation, irritability 
of svsiein. mental affections, amenorrhea and dysmenorrheea. It 
sometimes results from the constitutional irritation caused by the 
introduction of the vaccine virus into the system. It has also been 
observed as a complication of intermittent fever, and several instances 
are recorded of its occurrence as an epidemic affection. A variety 
named pemphigus indicus is described by Sauvages as a symptom of 
dysentery. 



HERPETIC AND BULLOUS ERUPTIONS. 241 

Chronic pemphigus affects principally aged persons, and adults with 
debilitated constitutions. It is also, but less frequently, met with in 
children. It appears usually in the autumn or winter season. The 
most fruitful causes of chronic pemphigus are those of a depressing- 
kind, such as fatigue, anxiety, intemperate habits, bad food, chronic- 
irritation of the gastro-pulmonary or genito-urinary mucous mem- 
brane, amenorrhoea, residence in damp and unhealthy situations, expo- 
sure to cold, and starvation. I once saw the disease as a sequela of 
scarlatina. In those most liable to this affection there is an habitual 
dryness of skin and deficiency of cutaneous secretion. Biett remarks 
that he has frequently found a fatty liver in persons who have died of 
chronic pemphigus. 

Dr. Whitley Stokes remarks that the causes of pemphigus gan- 
grasnosus are obscure. It seems confined to children, and attacks the 
finest in preference ; the children of the poor more frequently than 
those of the affluent ; and those who live in damp situations seem more 
particularly subject to it than others. The disease is more prevalent 
in summer than in winter, and appears to be infectious, though 
obscurely so. 

Two cases that have recently come under my notice led me to believe 
that pemphigus may sometimes result from the inoculation of the sys- 
tem by some poisonous principle. One of these cases was that of a 
surgeon who, eighteen months previously, punctured his right hand 
Avith a lancet which had just been used for opening a thecal abscess. 
The arm became swollen as high as the axilla, and was three weeks 
before it got well. Between three and four weeks after the cure of 
the arm a crop of pemphigus made its appearance on his left thigh 
and leg, and has continued to show itself from time to time up to the 
present period. The development of the bullge is always preceded by a 
febrile attack ; there- is a scalding sensation in the skin, and the next 
morning a crop of full-grown bullae are seen. 

The second case was that of a girl, aged twenty-two, who " poisoned" 
her right hand seven years ago, in cleaning brass with a red paste. 
Three or four days after the injury a number of ecchymosed spots and 
bladders made their appearance on her wrist and forearm, and have 
continued to trouble her until the present time. 

Prognosis. -—Pemphigus is dangerous in proportion to its complica- 
tions, and to the constitutional disturbance of the system. The acute 
variety is of little importance, but the chronic affection is always obsti- 
nate, and sometimes fatal, particularly in old persons. The disease 
would appear to exert sometimes a beneficial effect upon the system; 
thus Raver narrates that he "once saw a man who, after having had 
Beveral attacks of haamoptysis, became subject to chronic pemphigus 
of the legs, and from this period the bleeding from the lungs did not 
recur. The cure of pemphigus has, in some cases, been observed to be 
followed by various ill consequences." 

Treatment. — When the febrile symptoms arc acute, they must be 
met with purgatives, salines, and antiphlogistic regimen. The natural 
tendency of the disease is, however, towards debility, and it will gene- 
rally be found needful to have early recourse to tonics. 

16 



242 DISEASES ARISING FROM GENERAL CAUSES. 

In the chronic forms of the disease, tonics inust be employed at once, 
the best of them being acids and bark, the latter either in the form of 
infusion pr quinine. A valuable remedy in pemphigus is the hydrio- 
date of potass. In those cases in which the symptoms present obvi- 
ous indications of diseased action in any of the organs or viscera, such 
disorder should be made the especial aim of our treatment. Thus, 
when the alimentary canal is in a state of irritation, that irritation 
must be calmed ; when the mucous membrane of the bronchia is the 
seat of morbid action, counterirritants must be applied to the chest, 
and such other means adopted as will relieve those symptoms ; when 
the uterine function is disordered, ferruginous remedies must be admi- 
nistered. Restlessness and pain will be quieted by opiates. In an 
obstinate case of pemphigus, Rayer had recourse to arseniate of soda 
in small doses; in similar cases I have found Fowler's solution a use- 
ful remedy. 

The inflamed skin should then be thickly anointed with the ben- 
zoated zinc ointment; sometimes the old Turner's cerate or calamine 
ointment forms a convenient change, and sometimes the unguentum 
cetacei with liquor plumbi ; the unguentum plumbi compositum, the 
unguentum cretae compositum, the unguentum mellis, the unguentum 
cetacei with Peruvian balsam (5j ad §.])> the diluted juniper tar oint- 
ment, or an ointment of the nitrate of silver (gr. ij — - vj ad 5j) may 
be preferred. When moisture exudes from the bullae, or from the 
excoriated skin, the surface may be dusted with the oxide of zinc or 
starch powder ; and if the excoriations be very irritable and tender, 
a weak solution of the nitrate of silver in distilled water (gr. j — iij ad 
5J) will diminish the morbid sensitiveness. Fomentations are rarely 
of any advantage, and where the surface affected is large there would 
be difficulty in applying them. 

In the epidemic pemphigus gangraenosus, Dr. Stokes recommends 
an ointment of scrophularia nodosa, containing as much green vege- 
table matter as possible. He remarks that this is a traditional 
remedy, but he found it more successful than any other plan of treat- 
ment. The ointment should be warmed until it possesses the consis- 
tence of honey, and then laid on with a brush, and dressed with the 
same spread upon lint. The utmost gentleness should be used, and 
the dressing renewed every six hours. Where there is swelling of the 
surrounding parts, or when any powder has been previously used, he 
applies, in the first instance, a poultice of porter and oatmeal, or a 
carrot poultice in a state of fermentation. 

The diet in pemphigus, as soon as the febrile symptoms have 
subsided, should be nutritive and generous. 



FURUNCULAR ERUPTIONS. 243 



CHAPTER X. 

DISEASES ARISING FROM GENERAL CAUSES. 
FURUNCULAR ERUPTIONS. 

Under the head of furuncular eruptions, I propose to consider 
that common and well-known affliction of the skin, the boil, or 
FURUNCULUS, and that greater boil, the carbuncle, or anthrax, with 
whatever modifications they may chance to present. The general 
character of the furuncular eruption is an inflammation, extending 
deeply into the skin, forming more or less prominence on the surface, 
and resulting in the loss of vitality of a portion of the substance of 
the derma. The portion of the substance of the skin so destroyed is 
the heart of the boil, the core (coeur), and the suppuration which 
follows has for its object the separation and expulsion of the core. 
The degree of prominence of the boil would seem to depend on the 
depth of the portion of the skin attacked ; when the latter is super- 
ficial, involving parts which are looser in texture, and more susceptible 
of distension, the prominence is greatest, but when the inflammation 
sinks deeply, the prominence is less, although the mischief may be 
considerably greater, and the case in every way more serious, being 
attended both with a greater amount of pain, and being much slower 
in its progress. This, and the extent of the skin attacked, are the 
prime distinctions between the furuncul.us and the carbuncle ; in 
furunculus there is but one core, and the core is less deep ; in car- 
buncle there is more than one core, and these cores extend deeply into 
the derma. Thus mere size is only a secondary feature in the 
diagnosis between furuncle and carbuncle ; a large boil may be larger 
than a small carbuncle ; although the carbuncle, being an aggregated 
boil, is generally much more extensive than the furunculus, sometimes 
reaching to a diameter of six or more inches. 

The cutaneous diseases Avhich have formed the subjects of the 
previous chapters, have all been superficial in comparison with the 
furuncular eruption, and have resulted, as we have seen, in mere 
exfoliation of the cuticle, in effusion of lymph, and formation of pus, 
with no injury to the vitality of the skin : but now we have before us 
a disease in which the mortification of the part attacked is the 
principal and leading character; there is a concentration of infiamma 
tion ; that inflammation is of a destructive kind, and the death of the 
part affected is the immediate consequence. In a pathological point 
of view, I am of opinion that the purpose of the inflammation is 
elimination ; that the blood hurried on by the inflammatory impetus 
centres in a follicle, or several adjacent follicles, the representatives 
of the glandular function of the skin ; that partly from the violence 



244 DISEASES ARISING FROM GENERAL CAUSES. 

of the inflammatory impetus, and partly from the dense nature of the 
structure of that portion of the skin surrounding the follicle, the 
blood is arrested in its current, it becomes stagnant, and the part 
•which it has ceased to supply dies, while the stagnant elements of the 
blood are by a reparative process converted into pus, and constitute 
the subsequent suppuration. 

The characters of distinction between furunculus and anthrax relate 
to their prominence, depth, breadth, color, number of cores, and degree 
of pain. Furunculus is more prominent than anthrax, but the latter 
extends most deeply into the skin, and involves a greater breadth of 
the structure of the derma. The color of furunculus is a deep red, 
becoming, as the disease advances, more or less dull and bluish ; that 
of anthrax presents the same tints in a heightened degree, the deep 
red is still deeper and darker, often approaching a mahogany hue, and 
the bluish tint of furunculus becomes a deep purple and livid tint in 
anthrax. The core, which is single in furunculus, may be multiplied 
to twenty or thirty in anthrax, until the numerous openings formed 
on its surface for the exit of the cores give it the appearance of a sieve 
or cullender. Lastly, the pain, severe in furunculus, is more intense 
and more burning in anthrax. . 

Furunculus and anthrax, together with hordeolum, or sty, which 
is a small boil occurring upon the edge of the eyelids, in connection 
with one of the Meibomian glands, are grouped by Willan under the 
genus phyma ; the latter term ydfia derived from <pua>, produco, signi- 
fying a tuber, tubercle, or small swelling ; and applied by Hippocrates 
and the older writers to a suppurating tumor; hence the designations 
phyma furunculus, phyma hordeolum, and phyma anthrax. Phyma 
is the first genus of the Order Tubercula of Willan ; Plenck makes it 
a genus of his Class Bullae, under the popular term " Eiterblasen," 
pus-bladder ; while he places Terminthus, with the popular significa- 
tion " Erbsenblattern," i^ea-bladders, among Pustulse. The term 
furunculus is derived from furere, to rage, and is expressive of the 
severity of the pain which often accompanies this eruption ; while the 
term anthrax, oyOpa*, carbo, in quo dyOsl, id est, floret ignis ; a burn- 
ing coal ; indicates a greater degree of severity, and an intense burn- 
ing pain. To a boil which is more painful at night than during the 
day, the term epinyctis (Iruvtr/.Tiq on voxribp k'rsvero, quoniam noctu oritur) 
has been applied. Anthrax presents two varieties, not recognized 
at the present day, namely, pruna and terminthus. Pruna, from 
its resemblance to a small plum, a term applied by Avicenna, is a car- 
buncle surmounted by a black eschar; while terminthus, or tere- 
binthus, is a variety of carbuncle of which the core or slough has been 
likened in shape and color to the ripe cone of the pinus abies, or 
turpentine tree. 

The diseases included in the present chapter, as constituting the 
family of furuncular phymata, are, therefore, three in number, namely, 
furunculus. hordeolum, and anthrax. 



FURUNCTJLAR ERUPTIONS. 245 

FURUNCULUS. 

Syn. Phyma furunculus. Boil. 

Furunculus, or boil, is a small tumor, more or less prominent and 
conical, of a vivid or deep red color, hard to the touch, excessively 
tender and painful, slow in reaching maturity, suppurating imperfectly, 
and containing a central core or slough of mortified cutaneous tissue. 
After the ejection and separation of a grayish "and pulpy slough, the 
sore heals slowly, the affected skin remains for .some time congested 
and discolored, and a permanent cicatrix is left behind. 

Boils may occur on any and all parts of the body; they rarely 
appear as a general eruption, but are successive in their invasion ; and 
are usually more abundant upon some one region of the body than 
upon the rest, although by no means confined to a single region. 
Their common locality is the back of the neck, the shoulders, the 
armpits, the wrists and hands, the buttock, the perineum, the labia 
pudendi, the thighs, and the legs ; and they are more commonly met 
with in the thick skin of the back of the trunk and out&r side of the 
limbs than upon the front of the trunk and inside of the limbs. This 
remark does not, however, apply to the eruption when it attacks the 
armpits, the labia pudendi, the meatus auris, and the inside of the but- 
tock, all common localities. Among other situations, I have seen boils 
on the eyelids, on the nose and ears, on the integument around the 
mouth, on the cheeks, and on the scalp. 

The boil begins as a small red point in the skin, frequently painful 
from its origin, and tender to the touch ; passing the finger over it, it 
is felt to be harder, and deeper than a common papule, and the tissue 
around it is evidently condensed ; it is gradually and slowly expanding 
itself in the skin, and threatening the mischief which never fails to 
follow. Slow and certain in its progress, the integument is gradually 
raised into a prominence of a more or less conical' figure, the surface 
is at first red, then vividly red, then purplish red, sometimes a deep 
dull red, and sometimes purple, and even livid. After some days (four 
to six) a point is seen in the centre of the cone, showing that pus has 
commenced to form, or a blister is raised, the skin gives way, the pus 
escapes, the core or slough is brought into view, and, after a time, 
several (four to six), often many days, the slough is sufficiently loosened 
by the formation of pus between it and the sound tissue, to be thrown 
off; granulations are then formed on the surface of the cavity, the 
cavity contracts, the granulations shoot up and reach the surface, and 
cicatrization takes place; the process of reparation being extremely 
active (two to four days) when compared with that of the separation 
of the slough. 

The process now described is attended with pain, intense pain, 
erede experto ; the tumor is excessively tender, "as sore as a bile," 
and the pain is curiously increased at night, reminding us of one of 
the synonyms of the disease, namely, epinyctis. The great pain at 
night very probably results from the inactivity of the muscular 
system and the relaxation of the mind from its daily office, aided, no 



246 DISEASES ARISING FROM GENERAL CAUSES. 

doubt, by the horizontal position of the body, the warmth of bed, the 
stillness of the time, and the necessity for a state of calm and insensi- 
bility. The pain attendant on a single boil is prolonged for two, 
three, and sometimes four days; and when the eruption is successive, 
the pain of one is only obliterated by that of another, until the 
patient is worn out with suffering. Some persons are so happily 
constituted as to their nervous system, that they suffer but little, while 
others endure the most dreadful agony. Certain differences naturally 
result from the seat of a boil ; a small boil in the meatus of the ear 
pressing upon tissues incapable of resistance from their inclosure by 
bone and confinement by strong ligamentous bands, almost crushing 
the numerous and sensitive nerves of that region, nerves which are 
in intimate communication with all the most important nervous 
trunks of the body, is painful to agony, to frenzy ; while, by the 
same patient, a large boil in another situation, where from the nature 
of the tissues every facility of expansion exists, would be regarded 
as a mere inconvenience. A boil is painful in relation to the density 
or confinement of the tissues in which it occurs, and in relation to 
the neighborhood of sensitive nerves. A boil in a part of the skin 
supplied by the trifacial nerve, and involving a filament of that 
nerve, is intensely painful; so is a boil in the skin of the nose, tied 
down to the cartilages by an unyielding fibrous tissue ; or in the lip, 
where every beat of the coronary artery vibrates through the system ; 
in the perineum, where the skin is also fixed by strong fibrous tissue ; 
in the labium pudencli, where the part is apt to swell to almost burst- 
ing: in the armpit, where many filaments of nerves are distributed, or 
on the fingers, where the nerves are also abundant and sensitive. 

In an attack of boils, it is not all that run the course described in a 
preceding paragraph ; some stop at different periods of their progress ; 
some do not survive the stage of pimples ; others acquire a certain 
size, but neither suppurate nor slough; these are the so-called blind 
boils : they gradually and slowly subside ; their contents, if any, are 
absorbed; they entitle themselves to the distinction of indolent boils ; 
while a certain number only reach perfection. It sometimes happens 
that the local inflammation is not confined to the boil itself; it 
spreads to the surrounding tissue; the whole region is swollen and 
painful, and occasionally develops subcutaneous abscesses ; and some- 
times the absorbent vessels become inflamed, and the inflammation is 
propagated to the lymphatic glands, producing swelling, and some- 
times suppuration of those organs. Enlarged lymphatic glands in 
the groin from boils on the buttock or pudendum are not uncommon, 
and enlarged axillary glands, from boils on the hand or wrist, or in 
the armpit itself, are comparatively frequent. 

Furunculus is commonly accompanied with constitutional symptoms 
of a very slight description; but sometimes, when the pain is very 
intense and prolonged, the feverish symptoms run sufficiently high to 
call for antiphlogistic treatment. The pulse may be quickened, 
there may he pain ami tightness of the head, thirst, dryness of the 
tongue, languor, and restlessness, and the secretions may be deficient 
in quantity or arrested ; added to which, when the pain is excessive, 



FURUNCULAR ERUPTIONS. 247 

or when the boil is developed in the meatus auris, there may be 
delirium. 

HORDEOLUM. 

Syn. Phyma hordeolum. Stigh ; stithe ; stihan; 1 stian ; sty. 

Hordeolum, or sty, is a small boil occurring upon the edge of the 
eyelid, and involving a Meibomian gland. In its progress it is 
indolent, coming slowly to maturity, and presenting at its summit a 
single purulent point, and sometimes two or three. It is attended 
with much pain, causes swelling, and sometimes oedema of the eye- 
lids, and diminishes but sloAvly in size as it subsides, sometimes 
leaving behind it a chronic redness, which may last for several 
months. Commonly, hordeolum is single ; sometimes two are met 
with on the same lid; sometimes one or more exist on both lids; and 
sometimes both eyes are affected at the same time. 

ANTHRAX. 

Syn. Phyma anthrax. Carbuncle. Ignis Persians. 

Anthrax, or carbuncle, is a hard, circumscribed, flattened tumor, 
very little raised above the level of the skin, but extending deeply 
(an inch or more) into the cutaneous tissue. It is red in color, the 
redness being more or less vivid or dark at first, often presenting a 
mahogany tint ; then becoming more or less purple, then livid ; and 
after the separation of the sloughs and the healing of the skin, leaving 
behind it a chronic redness and deep brown stain, which lasts for a 
considerable time. The pain of carbuncle is very severe, and of the 
throbbing and burning kind ; the latter character having gained for 
it its twofold appellation of carbuncle and anthrax ; carbuncle signi- 
fying a little coal, and anthrax that same coal efflorescent with fire. 
When it has attained its full size, and the surface is purple or livid, 
the cuticle becomes raised into one or more blisters, numerous suppu- 
rating points appear in the skin, and these suppurating points are 
succeeded by perforations, through which the core issues from the 
stratum beneath in the form of sloughs, the sloughs being the fibrous 
tissue of the derma, converted into a grayish and whitish pulp, more 
or less soft and viscous, and mingled with an ichorous, purulent, and 
sanious discharge. Perforated all over its surface in this way, the 
face of the carbuncle has the appearance of a cullender or sieve. 
Sometimes, instead of numerous perforations, a portion of the skin of 
considerable size loses its vitality, and becomes converted into a black 
esobar, and the slough which follows is homogeneous and extensive. 
This is the pruna, or eschar carbuncle. At other times, and also as 
a consequence of the loss of vitality of a considerable portion of 
the centre of the carbuncle, the brownish or reddish-brown slough, 
isolated by suppuration from the surrounding living parts, broader at 
its base than its summit, and foliated on the sides by successive exten- 

1 Stihan, a Saxon word signifying arising, springing up, or ascent. "To sty," as used by 
Spenser, means " to soar, to ascend,'' as in the following couplet: 

" To climb aloft and others to excel, 
That was ambition and desire to sty." 



248 DISEASES ARISING FROM GENERAL CAUSES. 

sion of the sphacelus, has somewhat of the appearance of the ripened 
cone or fruit of a fir-tree. This idea in the poetical mind of our fore- 
fathers gave origin to the name terminthus applied to this variety of 
carbuncle ; terminthus being a mode of writing terebinthus, and 
referring to the turpentine tree, the pinus abies. 

Carbuncle, unlike boil, is generally single, and attains a considerable 
size ; sometimes, when small, there may be several dispersed on 
various parts of the body, as not unfrequently occurs in the furuncular 
epidemic at present existing. 1 Commonly, the carbuncle varies from 
two to six or eight inches in diameter, and one inch to one and a half 
in depth ; it is hard and dense to the touch, and feels as though it 
were imbedded in the skin. It is usually met with on the back of the 
neck, close to the occiput, or upon the back of the trunk. I have 
seen it frequently on the shoulder, the side of the trunk, or the loins ; 
and less frequently on the limbs. 

A large carbuncle is at all times a dangerous complaint, on account 
of the great pain which it occasions, the long continuance of that 
pain, the exhausting process requisite to separate the slough, and 
the irritative fever with which it is attended ; added to all, is the fact 
of its very existence being due to enfeebled powers of constitution ; 
but the danger of carbuncle is vastly increased by its occurrence on 
the nape of the neck, in which situation it is apt to excite erysipelas 
of a serious kind, and often give rise to congestion of the brain, an 
event which is usually fatal. 

Carbuncle is accompanied with more or less irritative fever and 
general disturbance of the nutritive, vascular, and nervous systems. 
It occasions loss of appetite and loss of sleep ; and when the pain is 
severe the patient is not unfrequently delirious. 

Diagnosis. — The distinguishing characters of the furuncular erup- 
tions are, their hardness, redness, depth in the substance of the skin, 
pain, and, at a later period, the deeper tint of color which they acquire, 
their perforation at the summit, the escape of so small and insigni- 
ficant a quantity of pus, and the subsequent appearance of the core or 
slough. Hordeolum, moreover, is known by its seat of development. 
The special characters which distinguish furunculus and anthrax, at 
the first appearance of the latter, are the conical shape of furunculus, 
and the flatness of surface and greater depth of base of carbuncle; at 
a later period, bulk, number of cores, tendency to suppurate imper- 
fectly in furunculus and slough in carbuncle, are superadded as further 
distinguishing features. The mutual relations and resemblances of 
the two diseases are further exhibited in the name which has been 
given to the smaller carbuncles, when only three or four cores exist, 
namely, furunculus anthracoides. 

Cause. — In referring to the books of our fathers of a few years 
back, we might be led to infer that boils were a proof of exuberant 
health, that they were indicative only of the most exalted powers of 
constitution, and that the plague of boils was one of the most desirable 

1 This furuncular epidemic commenced in lS. r )2 or 1853, and in 185G is still active. 



FURUNCULAR ERUPTIONS. 249 

events that could happen to youth and manhood. "The boil," says 
Mason Good, "is found in persons of an entonic or phlogotic habit, 
with a peculiar susceptibility of irritation;" therefore, he continues, 
this tumor is " chiefly found in persons of high health and in the vigor 
of youth." At the present day, however, this is certainly not the 
fact, for we see boils associated with debility in every degree ; we are, 
therefore, driven to the conclusion, that either the human constitution 
must have undergone a change since the time of our ancestors, or that 
altered atmospheric conditions have induced an alteration in the dis- 
eases of man. Probably both of these propositions are true; for, with 
regard to the first, we know that the free use of the lancet which was 
made by our predecessors could not be tolerated at the present time ; 
and with regard to the latter, we are aware that diseases of dyscrasia 
have increased of late years, and go on increasing; and that the gene- 
ral tendency of disease is to assume a low and debilitated form. 

During the last four years, namely, from 1852 to 1856, there has 
existed amongst us, and still continues to exist, an epidemic of boils; 
they afflict persons of both sexes, at all ages, and all seasons of the 
year, but I have never seen them occur in any one possessing genuine 
good health; there is always mal-assimilation, often cachexia, and fre- 
quently the boils are associated with other forms of cutaneous disease, 
such as eczema or acne. In this so-called furuncular epidemic the 
boils are for the most part small, and they have a frequent tendency 
to put on that form which is termed furunculus anthracoides, many of 
them having the character of small carbuncles rather than boils. 
They are also not unfrequently associatad with the push, a small cuta- 
neous phlegmon terminating in abscess; and sometimes large collec- 
tions of pus are formed in the neighborhood of the boils, as when they 
occur in the axilla or in the labium pudendi. 

The anthrax or carbuncle is a disease of the latter half of life, and 
of a debilitated constitution, being always associated with cachexia, 
and frequently with the gouty diathesis. This has always appeared 
to me to be the active cause of that monster carbuncle which is apt 
to form upon the back of the neck; and the cerebral congestion which 
frequently follow in its trains is a gouty congestion, allied to the gouty 
apoplexy which was so common in the winter of 1855-56, as almost 
to appear in the light of an epidemic. John Hunter remarks that 
carbuncle is a disease of a full habit and good living, and almost ex- 
clusively confined to the richer classes, and that he never saw but one 
case in hospital. This was, no doubt, true at the time that he wrote ; 
it may have been true also in reference to the selection of cases for 
treatment in hospitals, but it is directly opposed to my own experi- 
ence ; I have repeatedly seen carbuncle in the parish-workhouse, and, 
among the better class, in persons who were strictly abstemious and 
moderate in their habits, whose only excess was in mental pursuits, 
which indeed is a great source of deterioration and debility of the 
physical powers. 

Prognosis. — Furunculus, however abundant, is not dangerous, and 
with the restoration of the general powers is sure to get well. 
Anthrax is only dangerous when it occurs in a debilitated and 



250 DISEASES ARISING FROM GENERAL CAUSES. 

exhausted constitution ; when it is developed on the occiput and back 
of fhe neck ; and when any excess of gouty salts is allowed to take 
-ion of the blood during the progress of the disease or its treat- 
ment. 

Treatment. — "Bleed, purge," say our ancestors; "Don't bleed, 
don't purge," is the voice of the present day. Empty the bowels with 
mild aperients, restore the secretions as they may appear to require, 
but have the tonics close at hand for reader use as soon as these indica- 
tions are fulfilled; carefully avoid depressing the system farther than 
it is already depressed. I return to the enunciation of my law of 
treatment of cutaneous disease, to which the furuncular eruptions 
form no exception. Eliminate, for elimination is necessary; restore 
tone, for tone is wanting, and the prime cause of the defect of assimi- 
lation ; alleviate the local distress as best you may. * 

"We all know the improvement of power which results from the ac- 
tion of a simple aperient,' when the system is weighted down, is under 
a cloud of its own morbid humors; relieve this. When there has 
been feverishness, as is generally the case where much pain exists, 
particularly in carbuncle, I have followed up aperients, or combined 
with them antiphlogistic and effervescent salines ; I have secured 
healthy secretions, and then I have attacked the disease with tonics ; 
with the nitro-muriatic acid and gentian, or calumba ; with cinchona 
and sulphuric acid; with quinine and sulphuric acid; with the citrate 
of iron and quinine and citric acid, &c. It is astonishing, in these 
surgical cases, how little is left for the surgeon to do, if the physician 
play his part well. 

In anthrax the gouty salts are rarely absent ; therefore we must 
combine with our aperients, bitters and alkalies, gentian, calumba, 
quassia, chamomile, hop, taraxacum, with bicarbonate of potash (not 
soda), liquor potassre, iodide of potash, nitrate of potash, sulphate of 
potash, tartrate of potash, lemon-juice, &c. ; but we must bear in mind, 
at the same time, that all alkalies are lowering, are debilitating, and 
can only be used for a time, to be quickly followed by the mineral 
acids and bitters. Sedatives may be necessary both in furunculus and 
anthrax, and can be used with safety after the bowels are thoroughly 
relieved and the secretions regulated; and, with the same precaution, 
recourse may be had, if thought desirable, to colchicum. 

So troublesome and painful a disorder as furunculus has naturally 
-ted a variety of empirical remedies, which have obtained, from 
time to time, more or less credit, partly from the vehemence with which 
their merits have been extolled, and partly from some intrinsic value 
really existing in them. In some instances the principle of action of 
empirical remedies is obvious, and they are found to derive their repu- 
tation from their accidental use at the right moment, while at any other 
moment they would be mischievous and often dangerous; in others it 
is hypothetical, probably producing some chemical alteration in the 
composition of the blood, or affording an element necessary for assimi- 
lation. Of this latter class is yeast ; yeast taken in doses of an ounce, 
three times a day, is said to cure the furuncular diathesis. I have no 
experience of the remedy, and should have no objection to make trial 



FURUNCULAR ERUPTIONS. 251 

•of it, after I had prepared the system by the proper eliminants, and 
when the necessity for tonics was not a more presssing indication. I 
feel disinclined to speculate upon the "modus operandi" of yeast, 
until the fact of its usefulness is more fully established. As an 
external remedy, yeast, in certain cases, is amongst our best local 
applications. 

The diet in furun cuius, hordeolum, and anthrax, should be gener- 
ous and nutritious, with a fair proportion of stimulus ; sugar, potatoes, 
and beer, should be avoided, but meat and wine taken in moderation, 
and regulated according to the previous habits of the patient. Of 
wines, sherry, claret, dry champagne, and the Rhenish wines, are the 
best ; port, or rather the composition which goes by that name, the 
worst. 

And now as to local treatment, the last and least. Boils and car- 
buncles may be checked in their progress, and at least prevented 
reaching their full extent of size, by cold applications, by the liquor 
plumbi lotion, by the liquor plumbi diacetatis used pure, and pencilled 
on the coming tumor, and by an opium plaster spread on wash leather ; 
other remedies which I do not hold in the same repute, are pencilling 
with a solution of nitrate of silver in nitric aether (ten grains to the 
ounce); compound tincture of iodine, &c. 

When the boil or carbuncle advances in spite of these means, 
it should be covered with water-dressing, with Alison's prepared 
corium, or a linseed poultice ; and when it breaks, yeast may be 
added to the linseed poultice. The question often arises in the course 
of the treatment of boils, should they be punctured with the lancet ? 
and when-? Opinion is divided upon this question. I am against 
interfering with them unless the pain be very severe, or the boils 
threaten to assume a large size ; then, undoubtedly, advantage may 
be gained by free incision ; such an incision as will arrest the inflam- 
matory action by depletion, and relieve the tension, which is the chief 
cause of pain. Again, if the indication point to incision, the sooner 
it be performed the better ; after suppuration is established it is com- 
paratively useless. 

Taking the relief of tension and consequent pain, and the local 
abstraction of blood as the leading indications to determine the ques- 
tion of incision, we need never be at a loss to decide when it should 
be performed; and this question being set at rest, another arises as to 
how the incision should be practised. It should be free and deep, it 
should completely bisect the tumor, and if the tumor be large, the 
incision must be crucial ; a small incision does not effect the objects 
we have in view, it neither relieves the tension, nor does it unload the 
vessels completely, but, on the contrary, becomes an irritant, and adds 
to the evil which we are attempting to remedy. Incision must be 
thorough or none, there can be no intermediate course; and neglect 
of this aphorism has brought incision into popular discredit. I must 
not, however, be supposed to recommend the indiscriminate use of the 
lancet or knife ; all I wish to urge is, that if it be right to do, it should 
be done completely or not at all. 

In practising an incision in the case of boils and carbuncles, there 



ZOZ DISEASES ARISING FROM GENERAL CAUSES. 

may be present to our mind the possibility of an unseemly scar follow- 
ing the operation, and the pain which we are about to inflict on our 
patient. The first of these considerations applies chiefly to cases 
where the boil is in sight, as upon the face and neck, and may be met 
by regulating the extent and direction of the incision, which latter 
should always correspond with the natural folds of the skin. The 
other consideration, namely, that of the pain of the operation, may 
happily be controlled by chloroform, or by the congelation of the 
part with ice, according to the plan of Dr. James Arnott. 

Incision may, therefore, be practised on boils for the purpose of 
cutting short their progress, and as an ectrotic method of treatment: 
or they may be treated according to the plan previously indicated, by 
cold applications at first, and then by fomentation and poultices ; the 
multiple boil, or furunculus anthracoides, will more frequently require 
incision than the simple furuncle; and in anthrax the incision can 
hardly be dispensed with. If the carbuncle be treated for a while by 
cooling applications, fomentations, and poultices, and if, in spite of 
these remedies, it continue to increase in size, to give much pain, and 
excite considerable irritative fever, it must be incised at once, and 
without delay ; for unless this be done, exhaustion will soon follow, 
with delirium, and sloughing of the tumor to a greater or less extent. 

When a carbuncle is freely incised, the surface of the section is seen 
to be studded all over with the yellow and gray spots of the pus and 
sloughs ; and the substance of the hypertrophied derma looks spongy 
and worm-eaten ; sometimes large sloughs are brought into view, and 
a free exit is established for the stagnated blood, and pent-up collec- 
tions of pus and dead fibrous tissue. In debilitated and worn-out 
constitutions the loss of blood which follows the section of a carbuncle 
may be supposed to increase the exhaustion of the patient, but that is 
really not the case unless the hemorrhage be excessive. It is surpris- 
ing how much blood may be lost without inconvenience to the patient, 
the loss being completely compensated by the relief from pain and 
suffering which immediately succeeds the operation. 

Added to the other advantages which result from the treatment of 
carbuncle by incision is the saving of the skin from destruction by 
sloughing, a matter of importance in connection with the healing of 
the ulcer ; for, where much integument is lost, the cure of the ulcer 
is slow and protracted, and the cicatrix imperfect and unsightly. To 
obviate the pain of incision and the loss of blood attendant upon the 
operation, it has been proposed to open the carbuncle by means of the 
caustic potash ; but this mode of proceeding offers a more than counter- 
balancing amount of objections; the vessels are not relieved of their 
surcharge of blood, as in the plan by incision, and the destruction of 
integument by the caustic induces all the worst local consequences of 
carbuncle in respect of the healing of the ulcer and the production of 
an ugly cicatrix. 

During the suppurating and sloughing stage the carbuncle should 
be kept diligently poulticed with the linseed-poultice, the carrot- 
poultice, or the Linseed-poultice with yeast; or, when the weight and 
bulk of a poultice are objectionable, it may be kept covered with that 



FUKUNCULAR ERUPTIONS. 253 

excellent application, the invention of Dr. Scott Alison, the prepared 
corium or lambskin. The prepared corium, when saturated with 
water, is extremely soft, pulpy, adhesive and light, and possesses most 
of the advantages of a poultice without its objectionable qualities. 

Daniel Turner gives the following admirable account of his 
treatment of a furuncle, the "largest bile" he had ever seen : " When 
it was arrived to a cone, and I perceived the matter made, I passed 
in a lancet, and discharged a considerable quantity of well-concocted 
pus, under which, after two or three days' time, I found a large core 
or slough, extending, under the lips, the whole compass of the tumor ; 
to come at which I was under necessity to dilate both upwards and 
downwards ; then, filling up the ulcer with praecipitatum rubrum, 
and a pledgit spread with basilicon over all, I dressed him up, and 
left this dressing on for two days ; after removing which there came 
out therewith about one-half of the said slough. I continued this 
way of dressing till the ulcer was mundified, and being incarned with a 
mixture of the same basilicon and precipitate, cicatrized with dry lint and 
my ceratum de lapide calaminare ; more examples I think needless." 1 

The local treatment of furuncular eruption may be summed in a 
few words : First, allay the rising inflammation ; secondly, when the 
inflammation has reached its height, favor the formation of pus by 
means of the linseed-poultice : and thirdly, when the tumor has 
burst or been opened, and the process of separation of the slough 
moves tardily, assist that process by gentle stimulation. For the first 
of these three indications cooling and soothing applications are 
needed ; for the second, warmth and moisture ; for the third, stimu- 
lating remedies, such as the red precipitate and basilicon mentioned 
by Turner. The right remedy in the right place and at the right time, 
is an aphorism as applicable to medicine as to politics. In the 
employment of stimulants we must avoid irritation ; and a stimulant 
without irritation, and admitting of being graduated to any extent, 
we have in pressure, pressure by means of adhesive plaster, either the 
simple emplastrum plumbi on linen, calico, or wash-leather, or the 
emplastrum galbani et opii. In carbuncle, pressure applied in this 
way is invaluable for aiding the separation and expulsion of the 
sloughs. The coating of plaster has the further good effect of main- 
taining a proper degree of moisture and warmth of the part. 

Viewed according to this standard, we can understand the value 
and proper time for application of various popular and domestic 
remedies which have a reputation in the treatment of boils ; for 
example, the split fig, the honey poultice, and the cobblers'-wax 
plaster. The honey poultice consists of half an ounce of honey and 
the same quantity of melted lard, with the yolk of an egg, well mixed 
together, and inspissated to the proper degree by the addition of flour. 
The cobblers'-wax plaster is to be regarded as a digestive remedy of 
a somewhat active kind, suited only to the coarse skins and coarser 
podices of the rural population by whom it is employed. Turner 

• De Morbis Cutaneis. A treatise of diseases incident to the Sftin. Fourth Edition, 
1731, page 117. 



254 DISEASES ARISING FROM GENERAL CAUSES. 

observes that " the common people apply shoemaker's wax, a very 
uneasy application upon so tender a part ;" and he continues, " melilot 
emplaster, or basilicon, used by others, are much preferable, which 
both suppurate and often heal." Among the remedies in use in his time 
were a poultice made by boiling figs in milk, the lily root boiled in 
milk, and linseed boiled in milk ; these applications were frequently 
mixed together, and used in combination. 

The treatment of hordeolum should be the same as that of furun- 
culus : cooling lotions to subdue heat and inflammation during the 
first stage ; warm fomentations and poultices to encourage suppuration 
as soon as the first period is passed ; stimulants, such as the unguen- 
tum hydrargyri nitratis diluted, to disperse any swelling or induration 
that may be left after the matter is evacuated, and restore the part to 
its normal state. Constitutional treatment should not be neglected, 
the principle of treatment being the same as that for boils. 



CHAPTER XL 

DISEASES ARISING FROM GENERAL CAUSES. 
SCORBUTIC ERUPTION. 

Under the designation of scorbutic eruption I propose to describe 
a peculiar disease, which is characterized by the extravasation or 
effusion of blood into the tissue of the skin, the blood so effused 
giving rise to the production of purple and livid spots. The color of 
the spots has gained for the disease the name of purpura ; while the 
spots, presenting considerable variety of form and size, have been 
termed stigmata, petechia?, vibices, and eccliymoses, or ecchymomata. 
Stigma is the smallest kind of spot, a mere point or speck ; petechiae 
are small round spots, of about the size and bearing a close resem- 
blance to flea-bites (hence their name), but without the central point 
which marks the puncture made by the lancets of the insect ; vibices 
are larger than petechiae, and irregular in form, frequently resulting 
from the aggregation of several of the latter; while ecchymoses, or 
ecchymomata, are distinct and palpable extravasations of blood, 
presenting every variety of figure and dimension. 

Willan in his classification places purpura in the order Exan- 
themata, defining it as "an efflorescence, consisting of small, distinct, 
purple specks and patches, attended with general debility, but not 
always with fever." In the same group are assembled rubeola, 
scarlatina, urticaria, roseola, and erythema; purpura occupying a 
position between the two latter. With rubeola and scarlatina, pur- 
pura has no relation whatever, proceeding from a different nature of 
cause, and being totally unlike in its phenomena; with urticaria it 
has a slight tie, as presenting a variety in which a rounded, button- 
like elevation, very similar to urticaria, occurs, the variety being 



I 



SCORBUTIC ERUPTIONS. 255 

distinguished by the appellation of purpura urticans. To roseola it 
also bears a resemblance, in the bruise-like vibices, ecchymoses, and 
stains which follow some varieties of that eruption ; and to erythema 
it is distinctly allied, in its mode of manifestation on the skin. Never- 
theless, with all the foregoing points of similarity, purpura has 
appeared to me to be sufficiently distinct from the whole of these 
affections to merit the position in which I have placed it, namely, at 
the end of the seven forms of cutaneous eruption which originate in 
general causes. 

With the exception of the vibices and bruise-like stains which fol- 
low some of the varieties of roseola, purpura is sufficiently distinct to 
incur no risk of being mistaken for any other eruption of the skin. 
The deep red, blood-like, purple and livid spots occasioned by the 
blood particles escaped from their vessels, are totally different in color 
from the redness which is the result of congestion of the capillaries ; 
in the latter case, pressure by the finger empties the cutaneous vessels, 
and the congested spots, however vivid, immediately disappear ; but 
in purpura they are permanent under pressure, the effused blood may 
be compressed, but cannot be displaced from its position, and the spots, 
consequently, remain unchanged. Their ultimate removal from the 
skin is the result of absorption. 

In essential nature, purpura is an escape of blood from the capillary 
vessels, in other words, an extravasation of blood, in which morbid 
phenomenon both blood and bloodvessels participate. The blood 
itself is altered in quality, and deficient in fibrinous elements ; while 
the capillaries are no doubt softened in texture, and yield before the 
pressure of the circulation or any accidental pressure applied to the 
skin ; in a word, there exists a state of general cacochymia and dys- 
crasia, of which the morbid constitution of the blood and the general 
want of tone of all the tissues of the body, are but a part. 

Let us now proceed to examine the particular symptoms of this 
disease and its varieties. 

PURPURA. 

Syn. Purpurata apyreta. Purpura chronica. Porphyra, Mason Good. 
Jlosrnorrhoea petechialis, Adair. Plicenigmus petechialis, Sauvages. 
Petechia; sine febre. Petechial mendaces. Morbus pulicaris sine 
febre, Amatus Lusitanus. 3Jorbus maculosus. Macula.' niyrce sine 
febre. Ecchymoses spontanece. Land scurvy. 

In the long series of synonyms appertaining to purpura, the terms 
apyreta, chronica, sine febre, and spontanea, are all intended to point 
to a distinction between this form of eruption and that which accom- 
panies typhus and some other fevers. This is a purpura dependent on 
causes not inconsistent with a moderate amount of well-doing, as re- 
spects health, on the part of the individual; that is due to the destruc- 
tive alteration of the blood concomitant with a fever in which the 
vitality of the blood and of the tissues is seriously compromised. 
Both are symptomatic of exhausted power and debility, but in a, very 
different degree, and to an extent calling for a considerable difference 
of management. 



256 DISEASES ARISING FROM GENERAL CAUSES. 

The varieties of purpura, distinguished by Wil'an, are five in num- 
ber, of which four are generally admitted at the present day ; the fifth, 
purpura contagiosa, being the purpura above alluded to, as appearing 
in connection with typhus and typhoid fevers. The other four varieties 
are as follows : 

Purpura simplex, 

" hsemorrhagica, 

" urticans, 

" senilis. 

Purpura simplex denotes the most simple form of petechial scurvy; 
slighter in its characters and degree than purpura hemorrhagica, and 
unaccompanied, like the latter, with hemorrhage from the mucous mem- 
branes. Purpura urticans, as I have already remarked, is accom- 
panied with button-like elevations resembling urticaria ; and purpura 
senilis is an affection of the skin of a trivial nature, met with in elderly 
persons. 

PURPURA SIMPLEX. 

PorjyJiyra sinrplex, Mason Good. Petechial scurvy. 

Purpura simplex is an efflorescence of purple and livid spots on the 
skin, presenting the forms of stigmata, petechia, and vibices ; appear- 
ing in succession, and displaying at the same moment every grade of 
development, from the brighter hues of recent extravasation, to the 
purple and livid hue of a more advanced stage, and the yellow and 
brown stains of the fading eruption. It is commonly met with pretty 
equally distributed over the body; but on the trunk, the spots are 
most abundant on the breast and abdomen, and on the limbs, in the 
thinner skin of the insides of those members. The eruption is accom- 
panied with tingling, and with a moderate degree of soreness and ten- 
derness of the affected parts of the skin. At its decline the spots 
gradually fade and disappear, without exfoliation of the epidermis. 

The purple spots are sometimes seen in the mucous membrane of 
the mouth, nose, and fauces, and sometimes on the conjunctiva. But 
they are less frequently met with on the mucous membrane in purpura 
simplex, than in purpura hemorrhagica. 

The constitutional symptoms accompanying purpura simplex, are, 
some degree of languor and lassitude, a feeling of debility, a soreness 
of the muscles of the limbs ; a pale, broad, indented, and sometimes 
coated tongue ; a yellowish and murky discoloration of the skin ; 
bowels sometimes relaxed, and sometimes confined ; urine, sometimes 
scanty and sometimes abundant, sometimes deficient in uric acid salts, 
sometimes containing them in excess; and more or less oedematous 
swelling of the legs: in a word, the ordinary symptoms of mal-assimi- 
lation and cacochymia. I have a case of this kind before me at the 
present moment ; in the first week of May a gentleman consulted me 
for erythema attended with pruritus, and complained at the same time 
of a slight degree of sciatica, and some wandering rheumatic pains in 
his shoulders and arms. He had also a few blotches about the face, 
and exhibited symptoms of cachexia, induced by anxious and long- 



SCORBUTIC ERUPTION. 257 

continued application to his duties. In other respects, he was a man 
of atonic diathesis, someAvhat over temperate, and in the habit of fast- 
ing too long. I saw him twice, at intervals of a week, and was dis- 
appointed with the slow progress of improvement which he exhibited ; 
and on his third visit at the end of a month, he presented a fine speci- 
men of purpura simplex, with a yellow cachectic countenance, and 
oedematous lower limbs. The purple spots were numerous and dis- 
crete, and chiefly confined to the lower half of the body. 

In another case, occurring at about the same time as the preceding, 
the details were as follows: A merchant, aged forty-two, a single man, 
of temperate and abstemious habits, had applied himself too closely to 
the duties of the counting-house for some time, and had suffered in 
health as a consequence. He was pale, of fair complexion, far from 
robust or strong, and experienced frequent attacks of dyspepsia, con- 
stipation, and rheumatism. 

Towards the end of the year 1855, and after two or three weeks of 
dyspepsia, this gentleman was suddenly seized with rheumatic pains, 
which came on during the night. The pains were most severe in the 
axillae and across the chest and back ; and he had pains, also, in one 
of his hips. This attack was accompanied with rigors ; the bowels 
were constipated, urine scanty and high-colored, with red sediment, 
but the appetite was not affected. After ten days of suffering, he had 
administered to him a blue pill, and immediately following the action 
of the pill, and caused by the pill as he imagined, a crop of petechial 
spots made their appearance on his legs and arms. 

At the time of the appearance of the petechial spots, he suffered from 
great prostration of strength and depression of spirits, his muscles 
were sore, and he was unable to walk. After four days, during which 
fresh petechiae continued to appear, a crop of vibices suddenly broke 
out upon the lower limbs ; the vibices became tlie seat of bullae, which 
were filled with a purplish fluid; the integument was oedematous ; he 
avus unable to stir his legs, and there were scattered over them as many 
as twenty bullae at a time. These symptoms continued for six or 
seven weeks, when the petcchiae and vibices gradually faded, the skin 
got well, and he seemed to be recovering. 

Six weeks after this another attack of rheumatism suddenly took 
place ; he was seized as before with severe pains in the axillae, extend- 
ing across his chest and back ; the muscles of the back felt as if they 
had been bruised, and the rheumatic pains seemed to descend from 
his chest into the joints of his limbs. While in this state, he had 
administered to him five grains of blue pill on two consecutive nights, 
and immediately afterwards the purpura returned as before; firstly, 
as petechiae, and then as vibices on the legs, covered with bullae. 
With the petechiae and vibices the legs became swollen and hot, the 
muscles were sore, and he was unable to move them. At the end of 
a month the symptoms began to subside, and he was sufficiently well 
to come to London from a distant county to seek my advice. 

On the occasion of his visit to me in July, 1856, I found him com- 
plaining of languor and lassitude; his tongue was pale, there were no 
petechiae in the mouth, no spongincss of gums, or bleeding from any 

17 



258 DISEASES ARISING FROM GENERAL CAUSES. 

internal organ; his appetite was moderately good; and his bowels, 
usually costive, were regular. He made an average quantity of water, 
which deposited a red sediment; his pulse was weak, unequal, 126 in 
the minute, and he complained of occasional palpitations of the heart. 
His joints were still tender and somewhat swollen, and there were 
scattered over his arms and legs a plentiful sprinkling of petechige; on 
the legs there were vibices as well as petechia, but the bullae were 
dried up, and the cuticle was in a state of exfoliation. He remarked 
that he could always foretell an eruption of petechias by an increase 
of pain in his joints ; and, at these times, the slightest pressure on the 
skin would produce a bruise. The eruption itself gave rise to a little 
tingling, amounting, when the vibices were numerous, to some degree 
of pain, but not sufficient to cause anything more than a trifling incon- 
venience. 

This case is interesting, as showing the alliance between rheuma- 
tism with the lithic diathesis, and purpura, and this association points 
at once to the indications which we should follow in our treatment. 
I prescribed for him the tincture of gentian, with nitro-muriatic acid 
as a tonic ; and the guaiacum powder with bicarbonate of potash as an 
aperient; with a generous but moderate diet. 

One of my friends, of gouty diathesis, and subject to occasional 
attacks of lichen and eczema of the legs, has not unfrequently, in com- 
bination with this eruption, a pretty extensive development' of purpura 
both of the simple and urticating kind. The deep-seated soreness and 
bruised feeling of the limbs, extending deeply into the muscles, is very 
remarkable; as is also the stinging and prickling sensation in the skin, 
wherever the buttons of urticaria are developed. The neurotic nature 
of the disease is evinced by these symptoms ; and to an exhausted con- 
dition of nervous tone, may also in all probability be attributed the 
altered plasma of the blood, and the non-retentive power of the capil- 
laries and small bloodvessels. 



PURPURA HEMORRHAGICA. 

Porphyra hemorrhagica ; Porphyra nautica, Mason Good. Land 
and sea-scurvy. 

Purpura hemorrhagica is an aggravated form of purpura simplex, 
aggravated both in local and constitutional symptoms. The petechias 
and vibices are more numerous, and the ecchymoses more frequent 
and extensive; sometimes there are, besides, large vesicles or bullae 
containing blood. The mucous membranes are affected in a similar 
way with the skin; the gums are spongy, and bleed; and petechial 
extravasations have been met with in every tissue of the body, even 
on the brain and beneath the inner coat of the arteries and veins. 
The susceptibility to extravasation of blood is so great, that pressure, 
however slight, produces ecchymosis, and the folds of the skin are 
marked by an appearance of purple and livid stripes. In the mucous 
membrane, hemorrhages to a greater or less extent are not uncom- 
mon; and it is this character which has given the specific name to 
the present form of purpura. 



SCORBUTIC ERUPTION. 259 

The constitutional symptoms of purpura hemorrhagica are a 
repetition of those of purpura simplex, but in a more severe degree ; 
there is more languor, lassitude, prostration, and muscular debility. 
The pulse is feeble and quick ; there is more or less depression of the 
moral powers, and fever of the hectic kind. The frequent recurrence 
of internal hemorrhages increases the debility and hectic feverishness ; 
there is great faintness ; the limbs become ©edematous ; and the 
patient sinks from exhaustion, sometimes dying suddenly during the 
continuance of a hemorrhage, or from the effusion taking place in a 
vital part. 

The stigmata, petechia, vibices, and ecchymomata, present all the 
varieties and phenomena which have been noted in connection with 
purpura simplex, but in a heightened degree. They commence on 
the lower extremities, and extend by degrees to the trunk of the 
body, the hands and face being usually free. 

The duration of this disease, like its predecessor, is uncertain ; it 
sometimes lasts for months, and has been known to continue for years. 

It is this disease which at one time was so common in our navy, 
and was described under the name of scorbutus (purpura nautica), 
and which is found to prevail from time to time among masses of 
people congregated in unhealthy localities, and subjected to vicissi- 
tudes of temperature, particularly a cold and damp atmosphere, with 
bad and insufficient food, imperfect ventilation, exhausting fatigue, 
or deficient exercise, or a too prolonged use of salt provisions, and 
which is so effectually remedied and prevented by the reverse of 
these conditions ; namely, a dry atmosphere, good ventilation, good, 
fresh, and sufficient food, and proper exercise and cleanliness. The 
general symptoms of sea-scurvy are exactly similar to those described 
under the head of land-scurvy and purpura hemorrhagica, but often 
assume an exaggerated character. There is more physical prostra- 
tion, the skin is pale and discolored, the vibices are larger, the gums 
more spongy and bleeding, the breath very offensive, the excretions 
both from the bladder .and bowels fetid, the pulse weak and feeble, 
syncope frequent, hemorrhages more copious and general, and death 
a more common finale of the disorder. On the other hand, it has 
been observed in sea-scurvy that the physical depression is greater 
than that of the mind, that the latter is bright and vigorous to the 
last, and that the body dies suddenly from efforts made in obedience 
to the command of the will. 

PURPURA URTICANS. 

This form of purpura commences with round elevations of a 
whitish or pale color, sometimes reddish, which resemble the rounded 
wheals of nettle-rasb ; but there is generally less irritation and 
pruritus, and the wheals are less evanescent. When of a reddish 
hue, they have seemed to me to belong rather to erythema tuberosum 
than to urticaria ; they are somewhat elevated, generally well-defined, 
and soon become purple and livid, after which they subside slowly, 
leaving behind them brownish yellow stains ; as they are successive 



260 DISEASES ARISING FROM GENERAL CAUSES. 

in eruption, they may be seen in all their stages at the same moment. 
They occur, for the most part, on the lower limbs, and are commonly 
attended with some degree of oedema. I have seen purpura urticans 
most frequently in female servants, in whom it has been associated 
with uterine disturbance ; in similar cases, in fact, to those in which 
erythema tuberosum is apt to be found ; and I have also seen it asso- 
ciated with lichen and eczema. 



PURPURA SENILIS. 

The form of purpura described under this name by Bateman is not 
very infrequent in elderly women, particularly in those whose arms 
have been much exposed to local irritants of different kinds, such as 
the sun's rays, water, &c, and is always to be met with in our work- 
houses. It is associated with a preternatural degree of thinness of 
the integument, which is embrowned, yellowish, and mottled, being 
sometimes smooth and sometimes rigid and wrinkled. Bateman 
describes it so well that I quote his words : "It appears principally 
along the outside of the forearm in successive dark purple blotches 
of an irregular form and various magnitude. Each of these continues 
from a week to ten or twelve days, when the extravasated blood is 
absorbed. A constant series of these ecchymoses had appeared in 
one case during ten years, and in others for a shorter period, but in 
all, the skin of the arm was left of a brown color." The general 
health is in nowise affected in these cases, and the patient suffers no 
inconvenience beyond that of the unsightly appearance of the blotches. 

Diagnosis. — The purple and livid color of the spots; the blood 
being not in the vessels, but extravasated in the tissue of the skin ; 
the persistence of the spots under pressure with the finger : these are 
the distinguishing signs of purpura. The purple and discolored 
stains which follow some forms of roseola, and the purple pimples of 
lichen lividus, are distinguished by their connection with a distinct 
roseolous eruption on the one hand, and a papulous eruption on the 
other. 

Cause. — The cause of purpura is cachexia resulting from mal- 
assimilation : the mal-assimilation being one while the effect of 
generally depressing causes, whether physical or mental ; another 
while, the effect of improper or insufficient food, malarious atmosphere, 
excessive fatigue, defective ventilation, neglect of exercise and habits 
of cleanliness ; or, again, it may be the consequence of some organic 
disease, of local weakening of the tissues, as in anasarca, or of general 
and local weakening, as in old age. The severity or violence of the 
cause may be very different in different constitutions; in some, 
purpura is easily induced, and the affection is unimportant; in others, 
the system of the individual only yields when overpowered, and the 
disease is therefore grave. In the first of the cases which I have 
detailed under the head of purpura simplex, the mal-assimilation was 
induced by fatigue, abstinence, and some degree of mental anxiety, 
perhaps aided by some unknown miasma, proceeding either from the 



. SCORBUTIC ERUPTION. 261 

neighborhood of the residence of the patient, or from imperfect 
drainage in his own house. The mal-assimilation first evinced itself 
as a neuralgia; then as an erythematous eruption; then boils 
appeared ; and lastly, purpura with oedema of the lower limbs ; the 
skin of the face during the whole progress of the morbid phenomena 
being yellow and discolored. In the second case the cause was 
somewhat similar. 

Prognosis. — Purpura may be trifling or serious, according to the 
nature of the cause, the constitution of the individual, and the 
violence of the disease. Purpura simplex is very unimportant ; but 
purpura hemorrhagica is always serious, in consequence of its com- 
plication with internal hemorrhage, which may take place in a vital 
organ, as in 'the lungs, and prove suddenly fatal. 

Treatment. — The treatment of purpura offers no indication 
different from those for the treatment of cutaneous eruptions in 
general. We must eliminate, we must restore power, and we must 
remove the patient if possible out of the reach of the predisposing 
cause. For elimination, our remedies are saline aperients and effer- 
vescent salines ; sometimes we may think it desirable to begin with a 
dose of calomel or blue pill, to remove any irritant matters or secretions 
that may be present in the alimentary canal or in the ducts of the 
liver, or to induce a more healthy action of the liver and kidneys, or 
we may prefer rhubarb or guaiacum ; sometimes we may conjoin a 
tonic with an aperient, as in the infusion of roses with sulphate of 
magnesia and quinine ; or, having done as much by way of elimina- 
tion as we think desirable, we must endeavor to restore power, 
assimilative and vital, through the agency of our bitters and acids, 
bark and sulphuric acid; gentian or calumba, or hop, with the nitro- 
muriatic acid, &c. Sometimes in the presence of a lithic acid or gouty 
diathesis, the bitters, with mild aperient alkalies, such as the sulphate 
or phosphate of soda, or sulphate of potash, together with the iodide 
of potash, will do good service. We shall also derive benefit, in 
some cases, from the combination of the salts of iron with our other 
tonics, such as the hydrochlorate, the acetate, and the citrate of iron, 
with quinine. 

To the physical medicine must be added a moral medicine ; a rest 
from those exertions which have acted as a predisposing cause of the 
disease, change of air and scene, and particularly a sojourn for a time 
by the sea, together with tranquillity of mind. 

The diet should be moderate in quantity, but generous; and less 
abundant and stimulating during the febrile period than subsequently. 
Meat is one of the most wholesome as it is the most easy of digestion 
of all our articles of food ; it will afford the best materials of supply 
while the old and morbid elements are being removed by the elimina- 
tive process, and it will invigorate the blood and the entire organism. 
To meat may be added wine, or in some instances beer, as the 
physician shall see fit. 

Local treatment is rarely necessary, but if there existed any uneasi- 
ness of surface, which it might be desirable to relieve, the lotion of 
liquor ammoniae acetatis, diluted with one half of rose-water, or an 



262 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

emulsion of bitter almonds, will be found the most suitable for the 
purpose. 

In the sea-scurvy, lemon-juice and potatoes have obtained a de- 
served reputation, together with fresh meat and water, malt and spruce 
beer, and wholesome hygienic conditions. 



CHAPTER XII. 

DISEASES ARISING FROM SPECIAL EXTERNAL CAUSES. 

The special external causes capable of affecting the skin, and giving 
rise to irritation and inflammation, are three in number, namely, 
parasitic animals living in, upon, or under the skin ; heat ; and cold. 
Of the parasitic animals, the chief are, the acarus, the pediculus, the 
pulex, the cimex, and the filaria medinensis. The acarus scabiei lives 
within the skin, burrowing and depositing its ova in the epidermis, 
and drawing its sustenance from the juices of the true skin. The 
acarus autumnalis, or harvest bug, only makes a temporary sojourn 
on the skin, for the purpose of supplying its wants, and is merely a 
temporary infliction ; the pediculus also resides upon the skin, cling- 
ing to its surface, pediculus corporis ; or to the hairs, close to their 
exit from the follicles, pediculus capitis, and pediculus pubis. The 
pulex and cimex, the flea and the bed-bug, belong rather to the cover- 
ing of man, than to his proper self, attacking his skin only for the 
purposes of food. The filaria medinensis is a slender worm, of great 
length, a native of tropical countries, which forms for itself an abiding 
place in the subcutaneous cellular tissue, and sometimes gives rise to. 
considerable pain and inflammation of the part infested. As it is 
occasionally brought to this country, it calls for our attention with the 
present group. Lastly, the effects of heat and cold, the one causing 
burns and scalds ; the other gelatio or frostbite and chilblains, require 
no further illustration than that which they obtain under their respect- 
ive heads. 

The diseases originating from these causes, and to be treated of in 
the present chapter are, therefore, scabies, the inflammation of the 
skin caused by the acarus scabiei ; malis, the evil or disease caused by 
the presence of parasitic animals on the skin; ambustio, or burn; and 
GELATIO, or frostbite, the effect of cold acting destructively on the 
skin ; the latter head also includes that common cause of suffering in 
the winter season, namely, pernio, or chilblain. 



SCABIES, OR ITCH. 263 



SCABIES. 

Syn. Itch. Scabies papuliformis ; papillaris; vesiculosa; vesicu- 
laris ; lymphatic a ; pustulans ; pustulosa ; purulenta ; ulcerans ; ver- 
micularis ; cachectica ; Willan. Ecpyesis scabies, Mason Good. Gale, 
Fran. Kraetze, Germ. 

Scabies 1 is an affection of the skin characterized by scaliness of the 
epidermis, by vesicles, and in some cases by pustules ; to which may 
be added, excoriations, accidental abrasions, and scratches produced 
by the nails. 2 It is accompanied with excessive itching, the itching 
being augmented by warmth, and by the use of stimulating food and 
drinks. 

The above appearances are due to the presence of a minute animal- 
cule, the acarus scabiei, which burrows within the epidermis, and 
excites irritation in the papillary surface of the derma. The burrowing 
of this little creature gives rise to the scaliness (scabrities) and under- 
mined state of the epidermis. The vesicles, which are few and 
scattered, bearing no proportion to the number of the acari, and little 
relation to their seat, present some differences in form and character, 
resulting from their position. Thus, in the thin epidermis of the 
lateral surfaces of the fingers they are distinctly conical and acumi- 
nated ; on the wrists and other parts of the body they are frequently 
more or less rounded, and resemble the vesicles of eczema ; while in 
the latter situations they are also variable in size. The vesicles differ 
in reference to their contents ; in those of a conical form, the con- 
tained fluid is transparent and viscous ; in the rounded vesicle the 
fluid is also transparent, but in some it is more or less opaque and 
puriform. The pustules are present only in severe cases, or in persons 
with an extremely sensitive skin, for example, in children ; they are 
generally psydracious, and vary in size, from the small pustule of 
impetigo, to the larger pustule of ecthyma. 

When one of the early vesicles of scabies is examined with attention, 
a minute spot or streak may be observed upon some one point of its 
surface. This is the aperture originally made by the insect on its first 
entrance within the epidermis, and from this spot or streak a whitish 
fluted line may be traced either in a straight or a curved direction, into 
the neighboring epidermis. The whitish line is the cuniculus, or bur- 
row of the acarus ; it necessarily varies in length, being sometimes as 
much as five or six lines in extent, and at its termination, under a 
slight elevation of the epidermis, the little inhabitant lies concealed. 
The acarus may be easily distinguished by the experienced eye, as a 
small dark crescent, or as a minute white glistening orb, with a dark 
crescent i<- edge, at the end of the cuniculus, and if a thin capsule of 
epidermis be raised in this situation, with the point of a needle, the 
little creature is brought into view. 

The spot or streak which is here described is not met with on all 

1 Quasi scabrities. 

2 Portraits of Diseases of the Skin; Plate XVII., AA.; in which a good example of 
scabies is shown. 



264 



DISEASES FROM SPECIAL EXTERNAL CAUSES. 



Fig. H. 



the vesicle.*, for the same animal may excite a series of these in its 
course; and a number may be developed in the vicinity of its habita- 
tion, while in the primitive vesicle alone — that formed by the entrance 
of the acarus — it is, that the trace of its entrance can be expected. 
The aperture, again, does not communicate with the interior of the 
vesicle ; it is the too close neighborhood of the little grubber that acts 
as the cause of the formation of the vesicle ; the vesicle is consequently 
a provision of nature to protect the derma from the near approach of 
the cause of irritation. The acarus scabiei, therefore, is never situated 
within the vesicle or within the pustule, and there is no communication 
between the vesicle and the cuniculus. 

At a later period it is no uncommon thing to find at one extremity 
of the cuniculus the marginal outline of the base of the vesicle, while 
at the other end is the little dome under which the acarus is imbedded. 
The accompanying sketch is intended to illus- 
trate this appearance, the cuniculi (a) being 
about twice the natural size. The vesicular 
end of the cuniculus is a mere outline bounded 
by the broken edge of cuticle which formed 
the base of the vesicle, the rest of the vesicle 
having been removed by attrition and desic- 
cation. The next portion of the cuniculus, 
for about half its length was an open groove 
with a ragged border, while the remainder of 
the cuniculus was an arched canal or tubulus, 
somewhat expanded from point to point, where 
the animal made its temporary rest in its mole- 
like progress onwards. In the magnified 
figure (b) the acarus is seen at the end of the 
cuniculus; it resembles a white and pearl like 
glistening globule capped on its anterior 
border, or that which is nearest the end of the 
cuniculus, with a reddish brown crescent; the colored crescent being 
the chytinous investment of the head and anterior legs. Figure C 
represents the acarus removed from the cuniculus, and its appearance 
when seen with the naked eye through the thin convex plate of cuti- 
cle which covers it as with a watch-glass. 

The eruption of scabies usually makes its first appearance between 
the fingers ; from these it extends more or less quickly to the wrists, 
flexures of the elbow, axillae, inner sides of the thighs, and abdomen. 
In weakly constitutions it may be limited to the hands for a consider- 
able period without extending further, while in severe cases and san- 
guine constitutions it may speedily spread over the entire body, with 
the exception of the face, which is very rarely affected. 1 The excessive 
itching causes persons suffering from this annoyance to scratch, with 
violence, the seat of the eruption ; but the scratching only diffuses the 




1 The only case on record with which I am acquainted, of scabies affecting the face, is 
one mentioned by Alilnri The subject was an infant, and was supposed to have received 
the disease from the mamma' of its nurse. 



SCABIES, OR ITCH. 265 

pruritus, and the skin is often severely torn and abraded. When the 
points of the vesicles are broken, they become covered with small, 
thin, yellowish scales, and when they are made to bleed, they are 
occasionally followed by little black scales, like those of prurigo. 
When, in consequence of superadded irritation from susceptibility of 
the skin from scratching, from injudicious remedies, or from a ple- 
thoric state of the system, the vesicles take on the characters of pus- 
tules, the disease assumes the appearance which has been described by 
Willan under the name of pustular itch (scabies purulenta). 

The seat of the eruption of scabies is occasionally found to be modi- 
fied by circumstances. For instance, while, in the generality of cases, 
the disease is observed between the fingers and on the wrists, in those 
who, from hard labor or the manipulation of hard substances, have 
the epidermis of the hands and arms much thickened, it would be 
sought for in vain on those parts. In tailors and needlewomen the 
eruption is first developed on the hands ; 'and in infants, Rayer re- 
marks, that the vesicles are first perceived upon the breech. 

The activity and extent of scabies are strikingly modified by the 
state of constitution of the patient, its energy maintaining an exact 
relation with the vigor of the system. When the person is of sanguine 
temperament, and robust, the scabies spreads rapidly, and gives rise to 
insupportable pruritus ; when, however, the subject is weakly and 
infirm, or reduced by the presence of other disease, its progress is slow, 
the eruption partial, and the pruritus moderate. 

Although in cold and temperate climates scabies may be regarded 
as a mild and unimportant affection as respects the health, producing 
but little local disease, and no constitutional symptoms, yet in warmer 
climates, as observed by Dr. Adams 1 in Madeira, it is accompanied 
with pyrexia, and the local effects are often very severe. The itch- 
animalcule is very common in the island of Madeira, where it is called 
oucou or ouqam. The following case, illustrative of these remarks, I 
quote from Dr. Adams's account of these animalcules: 2 

" A patient (a European) applied to me on account of a spreading 
inflammation, attended with large vesications, collections of serum, in 
some places of pus, with intolerable itching, sometimes intense pain 
and smart fever. All these symptoms were much exasperated at a 
certain period of the day. I treated it like any other inflammatory 
complaint, with evacuants, and poultices to the part. The latter 
afforded some relief, but my patient grew extremely impatient from 
the fever and frequent violent pains, which deprived him of sleep. 
This induced me to examine the part with more care, and to convince 
myself that, how great soever the pain might be, the mischief extended 
only immediately under the cuticle. In the meantime, the female 
servant, who assisted with the poultices, pronounced the disease ouc'des, 
and to convince him of the truth of her assertion, extracted two from 
the edges of the sore, which he saw crawling on his nail. This appear- 
ance of the disease, so entirely local, and the part affected with such 
violence, was so different from anything I had met with before, that 

1 On Morbid Poisons. * Page 298. 



266 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

no evidence less than the above would have satisfied me. The pain 
indeed was less surprising when we consider the disease was imme- 
diately on the rete mucosum. Subsequent experience taught me that 
these symptoms are by no means uncommon. The disease yielded 
instantly to the usual topical remedy." 

Diagnosis. — One of the most important features in the history of 
scabies is the distinction of the disease from other cutaneous affections ; 
and this not only with reference to the mind of the patient, but also 
with regard to the management to be adopted. The treatment which 
is applicable to scabies would be improper in other diseases ; while, on 
the other hand, the means appropriate for the cure of other diseases 
would leave the itch in full possession of its mischievous activity. 
The chief diagnostic features of scabies are, firstly, a peculiar scaliness 
and undermined state of the epidermis, which -are not met with in 
other cutaneous affections'; secondly, its conical vesicles, with acu- 
minated and transparent points ; and thirdly, and principally, the pre- 
sence of the acarus, which may be extracted from its retreat beneath 
the loosened epidermis with the point of any sharp instrument. The 
diseases with which this disease is apt to be confounded are, eczema, 
prurigo, lichen, impetigo, and ecthyma. 

Eczema is a vesicular disease, and therefore bears some resemblance 
to one of the characters of scabies, but the vesicles are globular, and 
scarcely raised above the surface ; they are always collected in clusters, 
and give rise to a sensation of pricking rather than of itching ; more- 
over, eczema is not communicable by contact. 

Prurigo is a disease attended with thickening and considerable 
alteration of the skin, and unaccompanied by vesicles; it occurs on 
the back and shoulders, and the outer sides of the limbs, where the 
skin is thickest. The pimples of prurigo are frequently torn by the 
nails, and surmounted by little black scabs, which are characteristic 
of prurigo ; whereas the scabs which form on the ruptured vesicles of 
scabies are mere scales, and yellowish in color, a few only being 
black, when the scratching is carried to the extent of making the 
vesicles bleed. The pruritus of the two diseases, again, is different ; 
in prurigo it is burning, pricking, and painful, which is not the case in 
scabies, and, moreover, the disease is not communicable. Prurigo is 
occasionally met with as a complication of scabies, and in this case 
the diagnosis requires a nice discrimination. 

Lichen simplex, again, is a papular disease without vesicles, the 
pimples being for the most part thickly disseminated. When lichen 
occurs on the hands it affects the dorsal surface, and not the inter- 
spaces of the fingers ; the pruritus accompanying lichen is different 
from that of scabies, and the disease is not contagious. Lichen 
sometimes complicates the eruption of scabies. 

Scabies can only be mistaken for impetigo and ecthyma when 
complicated with pustules ; however, the limitation of the pustules to 
the hands or flexures of the joints, and the presence of the scaly 
epidermis and conical vesicles of itch, will be sufficient to determine 
the diagnosis. 



SCABIES, OR ITCH. 267 

Another complication of scabies frequently results from the irrita- 
tion of substances employed in the treatment of the disease ; it is an 
eruption of eczema simplex. I have seen cases wherein the treatment 
of scabies has been continued for upwards of six months, and the 
disease, to all appearance, has resisted the remedies employed for its 
cure. But in these cases the scabies was long since eradicated, and 
the obstinate eruption which continued was an eczema simplex, 
induced and perpetuated by the irritating applications used for the 
cure of the supposed itch. These cases immediately recovered when 
treatment was laid aside. 

Causes. — Scabies affects all ages, both sexes, and all ranks of 
society, but is most frequently seen among the lower classes, in whom 
personal cleanliness is neglected, and the opportunity of communica- 
tion consequently greater. When the disease makes its invasion in 
respectable families, its source may generally be traced to laundresses, 
servants, and their connections. 

Until very recently scabies was hardly known in London, nor 
probably in England ; it had disappeared even from our work-houses, 
and was rarely met with among nurses and children in private 
families. But since the return of the army from the Crimea the 
disorder is revived ; it has spread very extensively, and has found 
its way into a higher class of society than that in which it previously 
moved. Immediately upon the close of the war, scarcely a day 
passed without bringing me a case of scabies, chiefly in the person of 
a military or naval officer ; and at present I see several such cases in 
the course of a week, not however so much among the original 
introducers of the disorder, as in those to whom it has extended. 

The disease is always communicated by contact, either immediately, 
or through the medium of articles of clothing which have been in 
the possession of the infected individual. But there are many circum- 
stances predisposing to its influence, such as luxuriant health and vigor, 
sanguine or lymphatic temperament, the spring or summer season of 
the year, warm climates, youth, confined atmosphere, want of cleanli- 
ness, &c. The period at which the vesicles make their appearance after 
the invasion of the acarus, presents several important and remarkable 
modifications, having relation to the state of health and age of the 
subject, and the season of the year. Thus, in strong and healthy 
children, the vesicles have been observed at the end of two days after 
contact, the ordinary period for children being four or five days, 
while in those that are weakly the period of eruption may be still 
further postponed. In adults, the ordinary period of incubation is 
a week or ten days, but in the winter the eruption may not appear 
for a fortnight or three weeks. Old persons, again, require a still 
longer time for the development of the vesicles, particularly in the 
winter season. 

The proximate cause of scabies is the acarus scabiei, 1 which is 
transferred by the infected to those who are sound, by actual contact. 

1 The history of this animalcule will be found recorded in a separate chapter at the 
conclusion of the volume. 



268 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

In some instances it may be conveyed to the sound person in the 
adult state; while in others, ova, or embryos suspended in the fluid 
of the vesicles, may be the mode of transmission. Certain it is, that 
the application of one of these animalcules to the skin of a sound 
person Avill give rise to the disease. 

Some interesting and conclusive experiments on the habits of the 
animalcule were made, on the revival of the acarus scabiei in France, 
by M. Albin Gras, a pupil at Saint Louis, and published by that 
gentleman in the year 1884. 

Exp. 1. — "On the twenty-eighth of August," writes M. Gras, "in 
the presence of several physicians and students, I placed two living 
acari on the middle and anterior part of my fore-arm, and covered 
them with a watch-glass kept in its place by a bandage. On removing 
the apparatus on the thirtieth, we found two superficial cuniculi 
(sillons) half a line in length, and at their extremity two little white 
points, 1 indicating the presence of the acari. Substituting a fold of 
linen, retained in its place by a piece of adhesive plaster, for the watch- 
glass, the acari were left undisturbed for six days longer. At the end 
of this time the white points were no longer perceptible, and the cuni- 
culi having become obliterated, had disappeared." 

Exp. 2. — " On the first of September I placed seven living acari on 
my fore-arm, and covered them with a fold of linen, and piece of 
diachylon plaster. Four days after we found four or five well-marked 
cuniculi. On the sixth of September two of the acari being extracted 
from their cuniculi, were found active; they were then replaced. On 
the twelfth another animalcule was removed and examined ; it was 
quite lively. On the fourteenth there was considerable itching, with 
the development of a vesicle ; the cuniculi were two lines long. On 
the sixteenth there were several new vesicles near the cuniculi, but not on 
their line. On the seventeenth the vesicles of the previous day had 
been rubbed off by the linen, but two or three new ones were visible. 
On the following day I put an end to the experiment, by rubbing 
some sulphuro-alkaline ointment into the part. During the course of 
the experiment I suffered pruritus from time to time." 

Exp. 3. — " On the ninth of the month I imprisoned six acari on my 
ring finger, by means of the finger of a glove. Next day there were 
two cuniculi half a line long. The acarus of one of these burrows was 
apparent for ten days, the other for three weeks, but after this period 
they both disappeared. During this interval I cauterized several 
suspicious vesicles developed on the same finger, and discovered two 
new cuniculi originating in acari that had fixed themselves without 
having been observed. None of the vesicles appeared on the line of 
the cuniculi." 

Exf. 4. — " I lately placed nine acari in the bend of my left arm, 
and retained them there by a compress and bandage. Four hours 
after I felt pruritus, and next day perceived four cuniculi. Several 
days after, some vesicles showed themselves on my fore-arm." 

1 The dark brown crescentic speck produced by the color of the head and anterior legs, 
is certainly more striking as a diagnostic character than the white body of the animal here 
referred to; both, however, should be taken in conjunction. 



SCABIES, OR ITCH. 269 

Exp. 5. — "Having placed two acari in the flexure of the elbow of 
two persons, who expressed their willingness to submit to my experi- 
ments; on one, three or four vesicles were apparent on the fifth day, 
and were accompanied by severe itching. On the other there were 
two cuniculi, with pruritus, but no vesicles." 

Scabies is not limited to man ; it is not unfrequently seen in animals, 
and by them may sometimes be communicated to man. During the 
spring of 1840, I had the opportunity of seeing and treating a case so 
communicated, in the person of a veterinary surgeon, who had received 
the contagion from an ass upon which he was performing a physio- 
logical experiment. 

Prognosis. — Scabies is a mild disease, and little affective of the 
strength of the system. Some few cases have been recorded in which 
the eruption has subsided during an acute disease, -to reappear as soon 
as that disease had become someAvhat mitigated. Instances have also 
been advanced with a view to prove that certain serious visceral dis- 
orders have occasionally been developed, upon the sudden retroces- 
• sion of scabies. These statements are not borne out by observation, 
and refer to a period when scabies was the generic epithet for every 
disease of the skin attended with itching; but there is good reason for 
belief that a brisk attack of itch would rather be useful than other- 
wise, as a counter-irritant. 

Treatment. — The treatment of scabies is purely local, and numer- 
ous therapeutic remedies have been employed from time to time for 
its cure; moreover, as the object to be attained is simply the extermi- 
nation of the acarus, many have been successful. Several of these 
medicines act by means of their stimulating powers, and at the same 
time that they destroy the parasite, excite considerable irritation in the 
skin. Others, again, effect this object without causing irritation, or 
they give rise to much less inconvenience. In selecting our measures 
of treatment, therefore, our attention should be directed to the employ- 
ment of remedies which will act with certainty, and will produce the 
least possible degree of excitement in the cutaneous surface. Such a 
remedy is presented to us in sulphur, which may be regarded as spe- 
cific in the treatment of scabies. To effect the cure the sulphur is 
rubbed into the skin, and is conveyed by imbibition into the texture 
of the epidermis. Here it probably combines with hydrogen, and 
sulphuretted hydrogen gas is evolved, which acts as a deadly poison 
on the acarus, and destroys its ova. In some instances the sulphu- 
retted hydrogen gas in solution is employed as a wash or bath, and 
answers the purpose perfectly, but is longer in effecting a cure than 
the sulphur, probably on account of the gradual and constant genera- 
tion of the gas in the tissue of the epidermis, in the latter case. The 
sulphuretted hydrogen lotion gives rise to less irritation than the sul- 
phur ointment, and is therefore a preferable mode of treatment in 
children, and persons with a delicate skin. Before either of these or 
any other remedies are employed, however, it is desirable to prepare 
the skin for their reception by a thorough ablution with a warm solu- 
tion of subcarbonate of potash, containing about half a pound of alka- 
line salt to a gallon of water. 



270 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

To effect the cure of scabies in the shortest possible time, the best 
preparation of sulphur is the simple sulphur ointment, of which, in 
the adult, four ounces should be well rubbed into the entire skin, and 
particularly into the affected portions, morning and evening, for two 
days. It is desirable also, that the patient should wear a flannel 
shirt, and retain the same during the whole treatment. When this 
covering is not sufficiently large to envelop the entire body, he should 
also lie between blankets. On the morning of the third day the 
patient should take a warm bath, and wash the skin thoroughly with 
plenty of soap, when the cure will, generally, be found to be effected. 
Much, however, depends upon the manner in which the alkaline 
ablution and the friction of the affected parts shall have been per- 
formed. In some cases it maybe desirable, as a matter of precaution, 
to continue the inunction for a third day, or to use the white preci- 
pitate ointment 1 to the affected parts for a week or ten days, in case 
any ova may have escaped the influence of the sulphur treatment. 
In children one-half of the above quantity of ointment will be found 
sufficient. This method, while it offers the advantage of a rapid cure, 
is liable to the inconvenience of producing accidental eruptions. I 
am in the habit of combining with this plan the internal administra- 
tion of sulphur, in doses of a scruple or half a drachm, with a scruple 
of bitartrate of potash three times a day. And this I should recom- 
mend to be done, when the cure by inunction of lard or chamomile 
ointment is preferred. 

Reflecting on the rationale of the treatment of scabies by sulphur, 
we are led to the conclusion that the object to be attained is the 
thorough impregnation of the skin with the vapor of sulphur ; and 
then the question arises, whether this end is to be attained in any 
other way than that above described? In hospital practice, and in 
the case of children, it may be easy enough to saturate the skin with 
the sulphur ointment, and keep the patient within blankets to concen- 
trate the sulphureous vapor on the skin; but this plan is highly 
inconvenient, and often impossible, to persons engaged in occupations 
which require daily attention, let alone the annoyance that a man in 
perfect health must feel at being buried in blankets for a couple of 
days. Appreciating this difficulty, I have, for some years past, had 
recourse to a very simple method which I have found to answer the 
purpose completely, and which has the advantage of demanding no 
confinement and none of the heroic rubbings-in above described. 
My plan is to require the patient to rub into his hands, and particu- 
larly into the wrists and between the fingers a little sulphur ointment. 
This he repeats several times a day; for example, every time he washes 
his hands, and again at bedtime; the latter rubbing being a more 
thorough one than the rest. Moreover, at bedtime he further rubs 
the ointment into any other part of the body where the eruption may 

1 R. — Ung. hydrarg. ammoniocbloridi, 3£j. 

Mosclii, gr ij. 

Olei lavandulse, "VJj. 

Olei amygdalarum, 3J. — M. 



SCABIES, OR ITCH. 271 

exist. Then, besides the outward application, he takes from ten to 
thirty grains of the sulphur sublimatum twice or three times a day. 
In this way we secure a perpetual atmosphere of sulphur, and a 
thorough saturation of the skin, both from within and without, an 
amount of saturation, in fact, which no acarus can resist. The 
quantity of sulphur ointment required is small, and such as may 
be allowed to remain on the skin and between the fingers without 
detection by an indifferent person, and yet sufficient to answer all 
the purpose. This method of treatment destroys the acarus in the 
clothes as well as in the skin of the patient; and with the slight 
exception of giving him the smell of a brimstone match, a smell which 
he may cover with any kind of perfume, it is unattended with the 
least inconvenience. A week of this treatment, followed by a second 
or third week of a modified plan, for example, merely using dry 
sulphur-powder to the hands, instead of the ointment, and continuing 
the sulphur internally, will effectually cure the disease; and during 
its progress the patient may take a tepid or warm soap-bath every 
third clay. To protect the clothes not in use, shutting them up in a 
drawer, with some sulphur-powder sprinkled between them, will be 
found sufficient, and I also recommend the sprinkling of sulphur 
within the bed. 

The sulphuretted hydrogen treatment consists in bathing the surface 
of the body in a solution or bath of sulphuret of potash, containing 
one or two ounces of the salt to a pint of tepid water; or in sponging 
the skin with a mixture of two ounces of each of the following solu- 
tions in half a pint of tepid water, many times in the course of the 
day: 

R. — Sulphureti potassse, ^ij. R. — Acidi muriatici, gj. 

Aqua-, Oj. Aquie, Oj. 

M. ft. solutio. M; ft. solutio. 

The former of these methods is well adapted for young children, 
but the latter frequently creates considerable irritation, and produces 
accidental eruptions. The duration of treatment is a week or ten days. 

Numerous other preparations, sulphureous and non-sulphureous, 
and each possessing, according to their advocates, peculiar advantages, 
have been recommended by different authors. Among the more de- 
serving of these remedies are the following: 

Saponaceous Compounds. 

R. — Potassm snbcarbonatis, gij. R. — Sulphuris snblimati, 

Aqua, ^j. Saponis alb., aa Ibss. — M. 

Olei olivarum. t ^ss. 
Camphoru- gummi, gij. 
Sulpburis snblimati, ^v — M. 

The saponaceous compounds possess the advantage of riot soiling 
the habiliments of the patient, but they require a longer use than the 
sulphur remedies, namely, two or three weeks. 

Pyhorcl recommends the friction of half a drachm of sulphuret of 
lime with sweet oil into the palms of the hands without any applica- 
tion to the surface of the body, the treatment being continued for 



272 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

fifteen or twenty days. Fantonetti advocated the use of chloride of 
lime: and Delpech the employment of frictions of sweet oil alone. 
This last remedy would, doubtless, act most destructively upon the 
acarus, -could the oil reach the animalcule. In my own practice I 
have found sweet oil, containing a'little camphor, very successful in 
infants whose skin was too tender to bear sulphur ointment. And, 
carrying out the idea of the oily matter bearing a considerable share 
in the curative agency of the sulphur remedies, I have also employed 
inunction with lard alone with a satisfactory result. The lard requires 
to be well rubbed into all parts of the body, particularly into those 
chiefly affected, night and morning, and by the end of a week the cure 
is complete. A warm soap-bath should then be taken to purify the 
skin. Mr. Stiff, in a communication made to the Medical Tiines, in 
184"), is an advocate for this plan: and M. Bazin, in some trials lately 
made at St. Louis, states that six frictions with oil or lard are all that 
are requisite for the cure of scabies. 

M. Bazin, however, prefers an ointment of chamomile to the simple 
lard, and he states, as its advantages, that it cures in three frictions ; 
that it relieves the itching instantly; and that it gives rise to no 
secondary eruptions, as is the case with the sulphur and sulpho- 
alkaline treatment. His formula for making the ointment is to 
mingle equal parts of fresh chamomile flowers, olive-oil, and lard, and 
heat them together on a sand-bath. It appears to me that the same 
purpose would be gained by adding the essential oil of chamomile 
to lard. 

Among the simples recommended from time to time by different 
physicians, or employed popularly, are solution of tobacco, used by 
Boerhaave, but liable to many objections; stavesacre, hellebore, 
scabious, sweet-scented rush, elecampane, and onions. 

The use of stavesacre and hellebore have lately been revived, and, 
according to their respective suggestors, with flattering success. M. 
Bourguignon recommends that the patients should begin their treat- 
ment as usual, by taking a soap-bath ; that, after the bath, the staves- 
acre ointment should be well rubbed into the whole body, particularly 
into the parts chiefly affected; and that the inunction should be 
repeated four times a day. On the fourth day the cure is complete, 
and another soap-bath should be taken. M. Bourguignon's formula 
for the ointment is twelve ounces of powder of the seeds of stavesacre 
to be stirred into twenty ounces of boiling lard, and macerated in a 
Band-bath for twenty-four hours. It may then be strained, and some 
essences added to give it a pleasant odor. 

The formula proposed for the hellebore is, to mix together eight 
ounces of powder of white hellebore with four ounces of soft soap, and 
sufficient hot water to bring it to a consistence fitted for friction on 
the skin. It should be used once a day until all itching ceases, and 
then washed away in a warm bath. After a few frictions it produces 
a feeling of heat in the skin. 

Especial care should be taken that the whole of the garments worn 
by the patient, and the bedclothes in which he has lain, should be 



SCABIES, OR ITCH. 273 

disinfected by exposure to sulphureous acid gas. This is a measure 
of great importance, since the acari and their ova remain attached to 
all articles of apparel, and are easily communicated by them. Indeed, 
whenever practicable, the infected clothing should be destroyed. To 
complete the eradication of the animalcules, perfumes should be worn 
in the dress for several weeks. 

The treatment of scabies has been enriched by the observations of 
M. Albin Gras, in the work before alluded to. He observes: 

" I was enabled to obtain living acari from a patient who had taken 
two or three sulphur baths, containing four ounces of sulphuret of 
potass to the bath. On the contrary, I have frequently found them 
all dead after a single friction with the sulphuro-alkaline ointment." 
"But, although the insects are dead, vesicles still continue to appear 
for several days." 

" Immersed in pure water the acarus was alive after three hours ; 
in saline water it moved feebly at the end of three hours ; in Goulard 
solution it moved after an hour ; in olive-oil, almond-oil, and castor-oil, 
it survived more than two hours. In croton oil it was living after 
the lapse of an hour, but dead at the end of four ; in lime-water it 
was dead in three-quarters of an hour ; in vinegar in twenty minutes ; 
in alcohol also in twenty minutes ; but in naphthaline still more 
quickly ; in a solution of sulphuret of potass it was dead in twelve 
minutes; in spirit of turpentine in nine minutes; in a concentrated 
solution of hydriodate of potass the acarus ceased to exist in from 
four to six minutes; in a solution of arsenious acid it was dead in 
four minutes ; in sulphuric acid, diluted with three parts water, it 
died in three minutes ; in pure creasote, and in concentrated acids 
and alkalies, its death was immediate. Placed over night on powdered 
sulphur, the animalcule was found dead the next day ; and it required 
to be exposed to the vapor of burning sulphur for sixteen minutes 
before it died." 

One of the most remarkable of the phenomena of scabies, is the 
localization of the acarus to the hands ; while the eruption excited by 
it may be spread more or less extensively over the entire body. The 
animal is the excitant, and the excitation of the sensory nerves of the 
skin of the hands is communicated to the whole of the nervous appa- 
ratus of the skin, hence the itching and eruption on parts of the skin 
which the acarus never reaches. Hence, also, the principle of cure, to 
remove the local irritation, and thereby to subdue the excito-sensory 
phenomena which take their rise in the local irritation. But the 
morbid sensibility of the skin induced by the acarus, is often aggra- 
vated by the occurrence of the disorder in a person of eczematous 
diathesis ; in which case the eczema, in some one of its forms, becomes 
established and permanent, and requires the treatment of eczema for 
its removal. In such a constitution the acarus merely takes the place 
of a more common cause of the complaint, and the disease which 
ensues is not to be regarded as scabies, but in its true character as 
eczema or lichen, as the case may be. The treatment also must be 
that which is suitable for eczema, without reference to the scabies, 
which must be treated locally by the usual means ; or, as the eczema 

18 



274 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

is secondary in its development, the scabies may be cured first, and 
then the eczema may be attacked. After the first week of treatment 
specifically directed to the removal of scabies, the case must no longer 
be confounded with scabies ; the medical man must not yield to the 
belief that he has to do with an instance of unmanageable scabies ; 
and the patient must not be permitted to carry away the impression 
that his medical adviser is unable to cure the scabies. But to effect 
the cure the removal of the primary cause is essential. No treatment, 
however well directed, will benefit the eczema until the acarus is 
destroyed ; and when the acarus is effectually destroyed, as may be 
ascertained by the disappearance of all irritation about the hands and 
wrists, the treatment should be continued as for an ordinary and 
uncomplicated example of eczematous eruption. 

From these experiments we may infer, that sponging with vinegar 
would be a good practice, and one sufficiently harmless to be adopted 
in the case of the youngest children. 

MALIS. 

Die InsektengeschivuhtesiK-ht. 

The term malis, the fidkiq and fiaXtaafibq of the Greeks, is used as a 
generic term to signify the presence of parasitic animals on, in, and 
under the skin, and may be made to include the bites and stings of 
insects. The animals which are commonly found to draw their 
nourishment from the human skin are the acarus scabiei, acarus 
autumnalis, pediculus, pulex, cimex lectuarius, and filaria medinensis. 
The effects of the acarus scabiei, constituting the disease scabies, have 
been already examined ; there remain, therefore, to be considered, the 
nature of the suffering occasioned by the acarus autumnalis, and the 
remaining parasites. This will be discussed under the five following 
heads, namely, malis acari, malis pediculi, malis pulicis, malis cimicis, 
and malis filariae. 

MALIS ACARI. 

Crinones. Die Mitesser. 

The acarus, or mite, is very abundantly dispersed throughout 
nature, existing apparently wherever nourishment is to be found, and 
representing among terrestrial and air-breathing animals, the infusoria 
of the aqueous world. Acari are well known to inhabit vegetable 
substances, such as meal, dried fruits, sugar, &c, and to be the cause 
of their decay and destruction ; in like manner, it is found among 
animal substances, as cheese, dried meats, and fish, &c, gradually 
(•(inverting the nutritious parts to its own purpose, and leaving behind 
only that which is innutritious or resists its powers of disintegration. 
The surface of other animals, again, is a region in which animal 
matters of various kinds are to be met with, either in the form of 
excretions from the skin, or the juices of the skin itself; hence it is, 
that in this region we find the acarus revelling in abundance, sheltered 
among the lower animals by their hairy coverings, and provided with 



MALIS, OR CUTANEOUS VERMINATIOJJ. 275 

means of fixing upon and burrowing into the smooth and uncovered 
skin of man. 

To the observers of nature, the large _acarus which takes up its 
quarters on the under side of the common dung-beetle is well known. 
This creature probably takes advantage of the habits of the beetle to 
enjoy with him the feast which he laboriously buries in the ground. 
The acarus casei. or cheese-mite, is also familiar to all; but besides these 
common examples of the acarus, I have discovered it on the skin of 
the pheasant, in the mouse, and in the horse ; in the latter constituting 
the cutaneous disease termed the mange. 1 From these observations it 
may be inferred that every animal has its acarus ; and, judging from 
the great variety of form which the few examples I have had the op- 
portunity of observing have presented, I should be ready to conclude 
that each genus or even species of animal had its peculiar acarus, 
modified in its configuration and structure to suit the special circum- 
stances by which it may happen to be surrounded. Thus the meal- 
mite and the cheese-mite, imbedded in their food, require no special 
prehensile organs, and are chiefly remarkable for the bush of hairs 
which spring from their bodies to keep off the particles of their food 
and protect them from pressure and suffocation. The acarus scabiei 
is especially constructed for burrowing in the substance of the epider- 
mis ; he is furnished with a coat of plate and four strong arms in front, 
spines set backwards on his body, and four small weak legs behind. 
The acarus equi, much larger than the acarus scabiei, is also organized 
for burrowing : as in him, the legs are set forwards and backwards, 
the former being strong, the latter weak ; and he is additionally pro- 
vided with a pair of strong perforating organs, constituting a haustel- 
lum, the sides of the haustellum being furnished with recurved lateral 
hooks. Both the acarus scabiei and acarus equi have suckers attached 
to their feet ; but the acarus autumnalis, being only an occasional pa- 
rasite, and not organized for habitation in or on the skin, is only sup- 
plied with hooks to grapple with the surface while he is taking in his 
supply of food. 

The acarus scabiei and acarus autumnalis are the only two acari at 
present known which attack the human skin, at least in this country; 
but it is not impossible that in other countries and climates other 
parasites of the genus acarus may be met with. In illustration of this 
suggestion, I may mention that some specimens of acari were sent me, 
a few years since, from the United States of America, by Dr. Banbury 
Smith, with an account of the circumstances under which they were 
obtained. They were found on a lady residing in Stockholm. She 
was for a long time teased with them, and they gave rise to much 
inconvenience and vexation. The Stockholm acarus is of large size, 
^gth of an inch in length, by ^th of an inch in breadth; consequently 
somewhat more than three times the size of the acarus scabiei and 
acarus autumnalis. It is oval in form, and furnished with eight legs, 

1 The acarus equi will \><- found described by me in the Transactions of the Veterinary- 
Medical Association for lM'i-4, page 399. Some figures drawn with the camera lucida 
accompany the description of the animal. 



276 



DISEASES FROM SPECIAL EXTERNAL CAUSES. 



two of which are set forward and six laterally ; therefore the creature 
is not organized for burrowing. The legs are long, seven-jointed, and 



Fig. I. 



Fig. L. 



\L/ 




V 





Fig. I. — The itch animalcule, acarus scabiei, viewed upon the back; showing its figure and the arr 
ment of its spines and filaments. 
Fig. K.— The itch animalcule, viewed npon the under surface, showing its legs and tabulated feet. 
Fig. L. — The foot and last joints of the leg of the itch animalcule. 
Fig. M.— Ova of the itch animalcule. 



Fig. N. 



armed with a double tarsal hook, which would enable the animal to 
adhere firmly to the skin; its head is supplied with maxillae and palpi, 

or rather chelae, which are five-jointed ; 
and from between the chelae is projected 
a long, lancet-shaped haustellum. Judg- 
ing from the organization of this acarus, 
I should conclude that its presence on 
the skin of man was the result of acci- 
dent, that it drew its subsistence habit- 
ually from some other source, but that 
it was quite capable of piercing the 
cuticle, and obtaining its food from 
the juices of the human body, and in 
this way giving rise to considerable ir- 
ritation. Probably it is to this species 
of acarus that Rayer refers when he 
observes that " symptoms similar to 
those produced by pediculi, may be 
occasioned by aearides, an insect very closely allied to the ixodes, but 
capable, according to Bory St. Vincent, of forming a new class, 
characterized by a small sucker, accompanied with two feelers, con- 
sisting of four joints. M. Bory St. Vincent has observed these 
insects upon a woman of about forty years of age, who, after having 
experienced violent itchiness over the whole body, was very much 
astonished to see thousands of aearides on all the parts which she had 
scratched." 




Th- Stcckliolm acarus, viewed on its un 
der surface, and magnified :s8 diameters. 




MALIS, OR CUTANEOUS VERMINATION. 277 

ACARUS AUTUMNALIS. 

Harvest-bug. Mower s Mite. Wheal-worm. Rouget. 
The acarus autumnalis is scarcely larger than the acarus scabiei, 
measuring, in average numbers, about T ^o tn °f an i ncn m length, by 
the y^o^h °f an mcn m breadth; the average size of the acarus scabiei 
being T ^o tn of an inch in length, by yy oth of 
an inch in breadth ; consequently the acarus Fig - °- 

autumnalis is narrower than the acarus sca- 
biei, and flattened instead of being globular. 
It is of a reddish color, and provided with six 
legs and two chelae. The chelae are four- 
jointed, scarcely reach beyond the level of 
the maxillae, and are furnished at the extre- 
mity with strong nippers. The six legs spring 
from the thorax, are long, seven-jointed, and 
terminated by a short tarsus, with a pair of T * e ac f rus autumnalis > ™wed 

. nil mi i it • on its under surface, and magnified 

ample recurved hooks, lne haustellum is 70 diameters. 
concealed. 

The acarus autumnalis is most troublesome in the autumn season, 
and commonly during harvest, and is met with most abundantly on a 
chalky soil. It makes its attack chiefly on the legs of those who ven- 
ture into the fields during the harvest season, and from the legs finds 
its way to every part of the body, causing more or less irritation 
according to the susceptibility of the individual. Its bite is followed 
by redness and some degree of swelling, the amount of both depend- 
ing more upon the cutaneous sensibility of the person than upon the 
real injury done to the skin; sometimes the bite is followed by a small, 
glossy, red blotch, white, and raised in the centre, like a wheal of urti- 
caria, hence one of the names of the little animal, wheal-worm ; at 
other times the inflammatory congestion is as large as a crown-piece; 
or, when the bites have been numerous, a broad expanse of erythema 
may be the consequence. If the inflamed spot be examined with care, 
a small red point will be observed in the centre, this is the acarus; 
and it requires some dexterity on account of its adhesiveness to remove 
it from the skin. The irritation caused by this little creature, always 
troublesome, is, in some persons, so severe, as to amount for the time 
to a kind of torture. 

The best remedies for the bite of the harvest-bug, to destroy the 
animal and subdue the irritation are, spirits of wine, a lotion of ammo- 
nia, containing a drachm of the sesquicarbonate to eight ounces of elder- 
flower water ; a lotion of equal parts of sal-volatile and distilled water, 
the liquor ammoniae acetatis, distilled vinegar, the elder-flower oint- 
ment, or an ointment consisting of simple cerate with camphor. 

MALIS PEDICULI. 

Morbus pedicularis. PJtthiriasis. Die Laussucht. 
Three kinds of pediculi infest the human body, the pediculus capitis, 
pediculus corporis, and pediculus pubis. The pediculus capitis is 



278 DISEASE? FROM SPECIAL EXTERNAL CAUSES. 

found chiefly in children, but is not absent in the adult; the pediculus 
corporis is met with principally in the adult and elderly persons; and 
the pediculus pubis is more common in the adult than in the young. 

The pkdiculus capitis is protected from injury by the hair, and 
deposits its ova, commonly called nits, on the stems of the hairs; and 
the itching which it creates is said to be referable more to the move- 
ments of the animal on the skin than to the sting with which it is 
supposed to be armed; they are named pediculi, says Isidore, "quod 
magis pedum motu laedant, quam morsu." They are remarkable for 
the rapidity with which they multiply, and some of the phenomena 
to which their presence gives rise may be attributed to this circum- 
stance. Leuwenhoeck put their pow r er of procreation to the test of 
experiment; he "took two females and placed them in a black silk 
stocking which he wore day and night, that they might have the full 
benefit of feeding upon him. He found that in six days each laid fifty 
eggs without exhausting its store, and that in twenty-four days the 
young were capable of laying eggs themselves ; and carrying on the 
calculation, he estimates that the two females conjointly might pro- 
duce eighteen thousand in two months." 

The pediculus corporis is larger than the pediculus capitis, it is 
also whiter and flatter, and its ova are agglomerated and deposited 
among the body-clothes of the person. Just as the pediculus capitis 
never deserts the head, the pediculus corporis is rarely found among 
the hair, preferring the smooth parts of the body, to which it adheres 
closely. It is commonly met with in prisons and workhouses, and in 
those abodes of the poor where cleanliness and nastiness meet; less 
frequently in hovels, where the mingled odors of cooking, smoking, 
and match-making are diffused through the atmosphere. Pediculi 
have delicate noses, and are easily affronted by unseemly smells. 

Pediculi, like all other animals, are strongly influenced by the con- 
ditions among which they are placed; w T hen those conditions are 
favorable to their existence, they multiply to an enormous extent, 
and cover the body completely. This is the state to which the terms 
morbus .pedicularis and phthiriasis (<p0sip, pediculus) are particularly 
applicable. The irritation of these creatures on the skin, and the 
scratching of the surface which naturally accompanies the itching, 
give rise to more or less erythema and lichen, and sometimes to pus- 
tules, and then the skin presents the characters of a true disease. It 
is difficult to understand the extraordinary increase of these creatures 
on the skin in certain cases, even among persons of cleanly habits, and 
we cannot but come to the conclusion, that certain states of the fluids 
of the body are peculiarly favorable to their nourishment. Thus, they 
are sometimes found to be produced during an illness, and in some 
families have been known to invade the body shortly before death, 
and bo become an admonition of the approach of death. I have seen 
them terming on the bodies of persons laboring under malignant dis- 
ease, in whom the powers of life were scarcely sufficient to preserve 
the body from decomposition; and probably to this circumstance, to 
the exhalation of effluvia agreeable to their instincts, their presence in 
such excessive numbers might be attributed. Stories are on record 



MALIS, OR CUTANEOUS VERMINATION. 279 

relative to this disease that read rather like fable than truth, and yet 
may have had some truth for their basis. " It is recorded by authors, 
both ancient and modern," writes Daniel Turner, "that diverse persons 
have come to their ends, being devoured by lice, among whom the 
poet Alcmanes and Pherecydes Syrus, mentioned by Aristotle, are 
accounted." Riolanus says : "Felicitatem Syllse phtyriasis termina- 
vit ; eodom morbo Pherecides, Pythagorse preceptor, et Alcman peri- 
erunt." Of these last, Q. Serenus has these verses : 

"Sed quis non paveat Pherecydis fata tragcedi, 
Qui nimio sudore fluens. animalia'tetra 
Eduxit, turpi misernm quae morte tulernnt? 
Sylla quoque infelix tali languore peresvts 
Corruit, et foedo se vidit ab agmine vinci." 

Turner suggests another idea with regard to them in the following 
passage, they "are reckoned - to prognosticate death or speedy mor- 
tality to those they abandon, or when they, shift their quarters unpro- 
voked by medicine or external application." 

Some notion has been entertained of the development and existence 
of pediculi under the skin, and it has been reported by authors that 
tumors have been opened which were found full of lice. There is 
certainly no reason against the creeping of pediculi into the sacs of 
follicular tumors of the skin, feeding on their contents, and afterwards 
being found to be the sole possessors of these sacs, but in this case they 
have originally proceeded from the exterior, and crept through an 
opening which must have been overlooked by the observers in whom 
the report originated. It is clear from their organization, that pedi- 
culi are air-breathing animals, and that they cannot exist under or in 
the tissue of the skin where they would be deprived of that element. 

The pbdiculus pubis is very different in form from the preceding ; 
it is rather square-shaped than long; it is flat, has enormous legs, en- 
larging towards their extremities like the claw of a lobster or crab, 
and the body is covered with tubercles, from which proceed tufts of 
hair. Its resemblance to a crab has gained for it the appellation of 
crab-louse; while other of its names are plactulce, petals, and pessolatce 
(probably from its flatness), and morpiones. Although termed pedi- 
culus pubis, it is also found on other parts of the trunk of the body 
where there is hair, in the axillae, eyebrows, and at the roots of the 
eyelashes ; but however abundant on the rest of the body it is not met 
with on the head. 

The pediculus pubis gives rise to great itching, hence it has been 
named pediculus ferox; and by means of its strong feet, armed with 
a long recurved hook, which closes between two sharp spines, it is 
enabled to retain its hold upon the shafts of the hair with great tena- 
city, so much so, in fact, as to render its removal difficult, and scarcely 
to be effected without the loss of one or two legs. The difficulty is 
increased by the flatness of the animal, and by the smoothness of its 
back, over which the finger might pass without detecting its presence. 
To the eye it is more obvious, and is easily distinguished ; and the 
eye is further attracted to its haunts by the quantity of reddish fecal 



280 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

matter which it leaves upon the skin, entangled among the roots of 
the hair. 

The skin infested bj the pediculus pubis is always more or less 
torn by the nails; and sometimes it sets up a degree of irritation 
which pervades the skin more or less extensively, giving rise to an 
eruption of lichen. On the borders of the eyelids it is apt to create 
some degree of inflammation. 

Like the pediculus capitis, the pediculus pubis fixes its ova on the 
hairs, by means of the secretion which forms the horny capsule of the 
ovum. This substance, soft when excreted, soon becomes hard by 
desiccation, and establishes an inseparable adhesion between the ovum 
and the hair. 

The remedies most suitable for the treatment of the pediculus, 
whether infesting the head or the body, are the white precipitate oint- 
ment, scented with some pungent odor, such as lavender or camphor ; 
the red precipitate ointment ; l calomel ointment ; sulphur ointment or 
fumigation ; a lotion of the bichloride of mercury, and calomel in 
powder. Several simples have also retained a reputation in this com- 
plaint, namely, the seeds of the stavesacre in infusion ; the lesser 
centaurea in decoction ; the powdered seeds of the parsley ; wormwood 
seeds ; seeds of veratrum, lycopodium, rue, &c. 

MALIS PULICIS. 

Two species of the pulex or flea are commonly recognized, the 
pulex irritans, the common flea of this country, as well as of the rest 
of the world ; and the pulex penetrans, the chigoe or chiggre, a flea 
met with in the West Indies and South America. The former is 
merely a cause of irritation and annoyance ; the latter is capable of 
giving rise to a state of real disease. 

The pulex inflicts a deep wound in the skin, by means of a pair of 
very fine and sharp lancets attached to its head, and the sheath of the 
lancets probably acts the part of a haustellum in drawing the fluids 
from thq, wound. Its bite is recognized by a small circular spot or 
petechia, which it is sometimes important to distinguish from the 
petechia of purpura. In the petechia produced by the flea, a red point 
in the centre indicates the perforation made by the little animal, 
and this point is perceptible under pressure of the skin, while the 
pinkish disk, in the centre of which it is placed, disappears. In the 
petechia of purpura, on the other hand, there is no central puncture, 
and the whole spot remains under pressure of the finger. Occasion- 
ally, I have seen the petechia of flea-bites purplish in color, and 

1 The Scottish bard Burns seems to have been acquainted with the destructive proper- 
ties of tin' l mercurial rozel" for this purpose, as well as of '"fell red smeddum,'' which I 
take to mean red lead; he suggests their use in the following verse: 

" My sooth ! right bauld ye set your nose out, 
As plump and gay as ony grozet ; 
Oh ! for some rank mercurial rozet, 

Or fell red smeddum ; 
I'd gie ye sic a hearty dose o't, 

Wad dress your droddum." 



MALIS, OR CUTANEOUS VERMINATION. 281 

resembling small bruises ; in which case the distinction between them 
and the spots of purpura is not so obvious. As another ground of 
diagnosis, it may be observed that the petechise of purpura are more 
general than those produced by fleas. 

Fleas, like pediculi, have a great repugnance to powerful and fra- 
grant odors; and these may be employed as a means of protection 
against their attacks, at least when they are not impelled by too fierce 
a hunger. Lavender, musk, thyme, are all inimical to the instincts of 
the flea, and Linnaeus commends very strongly the seeds of the sea 
wormwood, absinthium maritimum, as a pulicifuge. 

The pulex penetrans, or chiggre, burrows beneath the skin, 
commonly of the feet, and by the side of the nails, or on the heels, 
and there deposits ova. This operation is attended with some degree 
of itching, and often the flea may be seen through the skin as a 
dusky spot. After awhile a small tumor, as large as a lentil, rises 
upon its place of concealment, and when the tumor bursts, it is found 
to contain a -small quantity of sanious pus, with an abundance of 
small, white, oblong bodies, which are the ova of the creature. The 
tumor is succeeded by a troublesome ulcer, which the hatching ova 
continue to irritate; new tumors are formed, followed by other ulcers, 
until the whole foot is in a state of inflammation. The attack of the 
chiggre is generally confined to the toes, and to the sole of the foot, 
but sometimes it invades the dorsum of the foot; and the ulcerations 
to which it gives rise have been known to occasion deep ulcers, 
with necrosis of the bones; and in some few instances mortification 
and death. 

The treatment of the chiggre is to remove the sac containing the 
ova without disturbing the latter, for if any of the ova are allowed 
to escape, the young pulices will prevent the healing of the sore, and 
all the inconveniences of the original disease will recur. The 
negroes and natives of the countries where the chiggre is found are 
peculiarly dexterous at this operation, which they perform with a pin 
or needle, and by great care succeed in dislodging the sac entire. 
After the removal of the sac, they dress the wound with the juice of 
tobacco. 

MALIS CIMICIS. 

The CTMEX lectuarius is a well-known scourge of large towns and 
cities; the creature lies hidden by day, but issues from its retreat at 
night, and feasts upon its victim, destroying sleep and rest, and 
covering the skin more or less extensively with inflamed and irritable 
bumps. The cimex has received its specific name of lectuarius, or 
leetularius, bed-bug, from being found commonly in the joints and 
crevices of the wood, of which the bed is constructed ; here it propa- 
gates largely, and is conveniently located for its nocturnal excursions. 
But it is not confined to the frames of beds alone ; it also takes up its 
abode in the crevices of the walls and of the floor, in the seams and 
under the folds of clothes; indeed in any situation where it can obtain 
concealment from the light. The creature is round, flat, and of a red 
color, is provided with a powerful haustellum, which it buries in the 



282 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

skin to reach the nutrient fluids of the body, and has a powerful and 
offensive cinnamon-like smell. 

The bumps occasioned by the cimex lectuarius are more or less 
raised and inflamed, according to the constitution of the sufferer. 
They are for the most part white and elevated in the centre, where the 
puncture is perceptible, and more or less deeply red in the circum- 
ference. They admit of being mistaken for erythema papulosum or 
tuberosum; sometimes they are accompanied with an extent of swell- 
ing amounting to oedema, particularly when they occur on or near 
the eyelids, and have suggested the idea of an incipient attack of 
erysipelas. In doubtful cases the diagnosis may be made clear by a 
knowledge of the cause, and by the presence of less swollen bumps of 
a similar kind on other parts of the body. 

The best application for the relief of the irritation of these inflamed 
bumps is, vinegar, Goulard's lotion, spirits of wine and water, or 
mindererus spirit, the liquor ammonias acetatis. 

MALIS FILARIiE. 

Helmintiasis. Die Hautwurm. 

The FILARIA MEDINENSIS 1 is a worm found under the skin in the 
southern countries of the world, and particularly in India. The worm 
is of about the thickness of a crow's quill, grows to the length of 
several feet, is white in color, and commonly single. There may be 
several worms in different parts of the body, but only one in the 
particular nest which the worm makes for itself in the subcutaneous 
tissues. It gives rise to redness of the affected spot, more or less 
swelling, and pain, all of which symptoms are subject to considerable 
variety; the redness may be more or less extensive, the swelling 
oedematous, and the pain very severe. In Hindostan it attacks both 
natives and Europeans, and has been known to give rise to so much 
inflammation and irritative fever as to have rendered necessary the 
amputation of a limb. 

The filaria medinensis is rarely seen in this "country, but it has 
been occasionally met with in persons returning from a residence in 
India. I have seen two such cases in young military officers ; both 
were out of health, and in one of the two I succeeded in performing 
the feat in which the natives of India are so expert, namely, of ex- 
tracting the worm. In this case the filaria measured more than a yard 
in length. 

One of the most striking phenomena in connection with these cases 
is the length of time during which the worm is latent, and develops 
no symptoms by which its presence may be surmised. Upwards of 
twelve months had transpired since one of these gentlemen left India, 

1 Medinensis, from the prevalence of t lie worm in the country of Medina, in Arabia. 
Iik medini of Avicenna; vermis medinensis; nervus medinensis; vena medinensis; vena 
civilis; tftrtwtl*. of the Greeks; dracunculus; Guinea worm. Some of the older physi- 
cians, as Galen and Soranus, were of opinion that the filaria was not a worm, but a 
"nervous concretion," hence the name nervus medinensis. "Pollux calls the dracunculus 
a piece of corrupted nerve." 






MALIS, OR CUTANEOUS VERMINATION. 283 

before he became aware of anything being wrong with his foot. He 
then had what appeared to be a small flat abscess on the instep ; the 
abscess burst, allowing a small quantity of sanious pus to escape, and 
with the matter a thin white cord, like a piece of bobbin, protruded 
from the opening. He drew out this protruding bobbin to the extent 
of a few inches, and in a short time the wound healed. Some weeks 
later he came to me with a small phlegmon on the side of the foot, 
and complained of its excessive painfulness. I recommended him to 
apply a poultice. A day or two later I perceived a fluctuating point, 
which I punctured, and a small white loop about an inch long was 
projected fr.om the puncture, with a very small quantity of sanious 
pus. I secured the loop, and drawing upon it gently, one end became 
released from the opening. The portion which remained measured 
four inches in length, and this I wound upon a narrow slip of card ; 
I then placed his foot under a stream of cold water, and winding as I 
proceeded, gradually and slowly drew out about six inches more. I 
repeated this operation daily for five or six days, and by that time 
had extracted the whole of the worm — that is, the whole of that 
portion of which the broken end had first appeared at the opening 
made by the lancet, this fragment measuring nearly a yard in length. 

On the occasion of his first visit to me, there was a good deal of 
pain extending up the limb ; he was unable to walk, and during the 
progress of the case this pain increased ; the skin was ©edematous and 
shining, the ankle swollen and erythematous, and the pain extended 
in the course of the nerves of the limb, as high as the groin. Once I 
was obliged to desist from any further traction on the worm for 
several clays, on account of the severity of these symptoms, which 
excited some irritative fever, and completely destroyed his rest at 
night, while the foot was so tender that he could not bear upon it the 
pressure of the bed clothes. My attention was attracted from the 
first, before I had discovered the cause of his suffering, to the extra- 
ordinary disproportion between the apparent local disease and the 
amount of pain of which he complained; and there was nothing in 
the slightly-flushed . and somewhat swollen blotch on the side of the 
foot to explain so much suffering. On looking at the smooth and 
shining skin covering the worm, I perceived a tortuous and slightly- 
elevated ridge, which no doubt corresponded with the burrow of the 
animal beneath, and which led me to give credence to the patient's 
suggestion, that the cause might be the guinea-worm; and having 
never seen a similar case, I watched it with attention; the result I have 
already stated. 

After each daily operation, a linseed poultice was wrapped around 
the foot and kept on until the following day. When the traction was 
commenced, from two to four inches of the worm came out easily ; 
then a little more force was required; this force became relaxed under 
the paralyzing shock of the stream of cold water ; but, after a little 
while, no amount of force, consistent with the integrity of the 
animal, could succeed in producinv: a particle more. When it came 
out easily the patient experienced no pain ; but when it came with 
difficulty, or resisted further traction, the pain was excessive, and 



284 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

finally, -when no more of the animal could be obtained, contributed to 
the necessity of putting a stop to the operation. The piece of card 
was then secured near the aperture of the opening until the next 
day. 

It appeared to me that the inflammatory process, and the suppura- 
tion which ensued, weakened the vitality of the animal ; and that, to 
secure its existence, it was necessary that it should be enabled to 
burrow in the tissues and feed upon them, without occasioning that 
amount of excitement which results in inflammation. This idea is 
borne out by the fact of no symptoms of the presence of the worm 
being experienced until the animal has attained the prodigious 
length of several feet ; that then, for the first time, and as though 
from the accident of its coming too near the sensitive tissue of the 
skin, inflammation is set up, and the inflammation is followed by a 
scanty suppuration. Bathed in the heated fluid of the inflamed 
tissues, the worm becomes debilitated and exhausted ; and when the 
abscess bursts, or is opened, a torpid loop of the creature is ejected 
through the opening. This loop may be handled without exciting 
contraction or motion ; it looks soft and swollen, and sometimes is so 
much softened that it breaks easily; it "is also of a different color to 
the more vigorous part of the worm ; the latter is somewhat trans- 
parent ; its internal structure may be seen through its tegumentary 
coat, it is firm and even rigid ; the extruded loop, on the other hand, 
is of an opaque white color, and soft. These differences, moreover, are 
perceptible in the daily operations on the worm ; the first portion, 
weakened in vitality by exposure at the aperture by its unnatural 
confinement around the slip of card, and by its contact with purulent 
fluid, is soft, swollen, and opaquely white; it yields easily to the 
effort of traction, to the extent of two, three, or four inches ; it then 
becomes thinner, more transparent and firmer, and soon resists every 
amount of force that can be used for its extraction ; appearing from 
the pain which it occasions, to clasp with its coils the walls of the 
tortuous burrow in which it is concealed, perhaps clutching fiercely on 
the thread of a nervous filament. The cold water, falling upon 
its bed from a height, paralyzes its muscular structure for a moment, 
and an inch more of the creature is wound upon the card, until, in a 
few minutes, it seems to become part of the flesh itself, and to be 
immovable. After days of careful and laborious winding of this 
creature, I was agreeably surprised, on the last day, to find it come 
out without difficulty, even to the end, perseverance and gradual 
encroachment had finally exhausted its vitality and powers of muscular 
resistance. 

After the extraction of the worm all pain ceased immediately, and 
the sinuous ulcer in which the creature had lain imbedded speedily 
healed. In the second case that came under my notice, there was 
more pain and inflammation of the foot than in the first, and the 
worm was so soff as to preclude the use of any force in the attempts 
made to extract it. At last, after about eighteen inches had been re- 
moved, it suddenly broke, and the end became retracted within 
the skin. As we could not hope to recover the worm, after this 



AMBUSTIO: BURNS AND SCALDS. 285 

accident, for a week or more, I counselled my patient to go into the 
country to recruit his health, and to return to London as soon as he 
perceived any reappearance of the worm. He paid me a visit after 
a few weeks, but it was only to say that he had seen nothing more of 
his enemy, and that his foot was quite well. I was not surprised at 
this report, for it appeared to me that the creature had been destroyed 
by the inflammation and suppuration, and that the inflammatory action 
had occasioned a spontaneous cure. Whether this result would have 
followed in the native country of the animal, it is difficult to say ; pro- 
bably it would not. 

Another remarkable phenomenon in the history of malis filarise is 
the curious fact of the isolation of the animal ; and this is the more 
extraordinary, as the sanious pus which exudes from the sore teems 
with hundreds of young filariee, all minute and all of the same size. 
Why these young filarige do not grow to the size of the parent and 
propagate in the tissues of the skin is most difficult to decide ; but 
all our records of the history of the animal tend to show that such 
is not the case. And the question suggests itself, are these minute 
worms the young of the Filaria, or do they belong to a different 
species ? 

AMBUSTIO. 

Burns and Scalds. 

Under the head of ambustio, or burn, we have to consider those 
morbid conditions of the skin and subjacent parts which are produced 
by caloric in a concentrated form, whether the immediate agent of 
injury be irradiated heat, as that from the sun and bodies in a high 
state of temperature, or whether it proceed from the direct contact of 
flame, boiling fluids, or heated solids. Proceeding from sources so 
different, heat will vary in its degree of intensity, and it will also vary 
in its effects upon the skin according to its duration or continuance. 
The rays of the sun, however powerful in themselves, are not to be 
compared with the sudden contact of flame, and the latter is inferior 
in power to the more prolonged contact of boiling fluids or heated 
metal. Thus, in degree, heat may be feeble but prolonged ; or it may 
be strong and instantaneous; strong, and continued for a brief period; 
or strong, and continued for a long period. 

These differences in degree of heat, and duration of its action on the 
skin, necessarily give rise to differences in effects, such differences con- 
stituting the degrees of burn, noted from the earliest period of their 
history, and recognized universally at the present day. Daniel Turner 
divides burns — 

1. "Into such as are superficial, where the skin is lightly scorched, 
and the cuticle raised into blisters. 

2. " Such as go farther, not only blistering the scarf-skin, but alter- 
ing the texture of the skin itself, which comes away in a light slough. 

3. "Into those which penetrate still deeper, burning not only the 
skin, but flesh and other parts subjacent, into a coal or crust." 



286 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

Dupuvtren lias enlarged and improved on this division of burns; he 
makes six degrees of severity, which he classifies as follows: 

1. "Erythema, or superficial inflammation of the skin without ve- 
sicles. 

2. " Inflammation of the skin, with separation of the cuticle, and 
the production of vesicles filled with serum. 

3. "Destruction of the papillary layer of the skin. 

4. "Disorganization of the entire thickness of the skin, down to 
the subcutaneous cellular tissue. 

5. "Destruction of all the superficial structures, together with the 
muscles, to a variable degree of depth short of the bones. 

6. " Carbonization of the entire thickness of the burned part." 
For our present purpose, and with especial reference to the skin, it 

may be convenient to classify burns into three groups, namely: 1. 
Erythematous burn; 2. Vesicated burn; and 3. Gangrenous burn ; leav- 
ing the two degrees of destruction of the true skin, and the two degrees 
of destruction of parts beyond the skin, as sub-varieties of the latter. 

Erythematous burn (ambustio erythematosa) is characterized by 
a vivid and diffused redness of the skin, some degree of swelling, and 
a pungent smarting pain. The pain continues for some hours ; the 
redness subsides in a variable period of time, several hours or days, 
according to the severity of the burn, and is followed by desquama- 
tion of the epidermis, and gradual restoration of the skin to its natu- 
ral state. 

Erythematous burn may be occasioned by exposure to the heat of 
the sun's rays in hot weather or hot climates, and particularly if the 
part exposed be one usually covered by the clothes ; or it may result 
from the momentary action of hot water or steam, or from long sub- 
jection to the heat of a fire. The erythematous burn produced by 
insolation or the heat of the sun's rays is commonly called ephelis 
solaria (&rl V ; "~, the sun) ; it occurs chiefly in the summer season, and 
generally in women and children, or persons not habitually exposed 
to the sun's influence. After the first effects of the erythema have 
subsided, the epidermis becomes thickened, and desquamates repeat- 
edly; the color of the skin changes to a reddish brown, which is more 
or less permanent; and the skin loses a part of its sensitiveness to 
outward impressions. 

Erythematous burn occasioned by the prolonged action of the heat 
of fire on the skin, is illustrated in an affection more common in France 
than in this country, the ephelis ignenJis. This form of ephelis is 
known by a mottled or marbled appearance of the skin, occurring, for 
the mosi part, on the legs and thighs of women, and immediately re- 
sulting from the heat of the charcoal brazier, or chauffrette, which they 
use for warming themselves in the winter season. The mottled patches 
are of a reddish brown color, partly owing to dilatation and congestion 
of the capillaries of the skin, and partly to increase of cutaneous pig- 
ment; and by long continuance of the habit, the mottling assumes a 
deep brown tint. 

The constitutional symptoms of erythematous burn are insignificant 



AMBUSTIO: BURNS AND SCALDS. 287 

or absent altogether, if the burn be slight, of small extent, or the indi- 
vidual insusceptible ; but, under the influence of opposite conditions, 
particularly if the burn be extensive, the action of the heart may be 
accelerated, and there may be more or less of irritative fever, with 
gastric or intestinal disturbance. When the head is the seat of the 
burn there may be sleeplessness and delirium, followed by coma and 
death. " Cases are related," says Dupuytren, " where persons in hot 
countries, having gone to sleep in the open air, have been so scorched 
by the rays of the sun that a violent inflammation of the skin has 
resulted, the inflammation has been followed by gangrene, and they 
have died on the fourth or fifth day." 

Vesicated burn (ambustio vesicularis), the second degree of burn 
of Dupuytren, is indicated by the development of vesicles (ambusta, 
uritis) on the inflamed and erythematous skin. The vesicles some- 
times appear immediately, but more frequently after the lapse of a few 
hours; they vary in size, and are filled with a transparent serum; 
occasionally a part of the epidermis is removed at the time of the burn, 
and then the local action is more severe, and results in suppuration. 
The inflamed skin is pervaded with an intense burning and smarting 
pain ; and as it becomes swollen, the pain is increased by a sense of 
tension. When the vesicles are broken or rubbed off, the excoriated 
derma is acutely sensitive, and becomes quickly covered with a gelati- 
nous and whitish film of coagulated lymph, which serves to protect it. 
Sometimes, after the first symptoms are past, the pain, swelling, and 
redness subside, and the skin, after exfoliation of the epidermis, re- 
turns to its natural state, without leaving any trace behind; at other 
times, and especially when the epidermis has been removed at the time 
of the burn, suppuration and, sometimes superficial ulceration are set 
up, and the burn rarely gets well without leaving a cicatrix. 

The constitutional symptoms accompanying vesicated burn are more 
severe than those of the erythematous kind; the shock to the nervous 
system being greater, and the chances of internal congestion more 
probable; moreover, the danger is increased as the subject of the acci- 
dent is more excitable and delicate. I once met with the case of a 
young child who, standing before the fire warming its hands, was 
struck on the chest with a jet of boiling water from the spout of a tea- 
kettle. The inflamed spot was little larger than a crown-piece; the 
epidermis was raised into blisters. Eleven hours afterwards the child 
was seized with convulsions from cerebro-spinal irritation, and in 
nineteen hours was dead. 

Gangrenous burn (ambustio gangrenosa) comprises the third and 
fourth degrees of burns of Dupuytren; the third degree being that 
in which the papillary layer of the derma is alone destroyed; the 
fourth degree being the destruction of the entire thickness of the 
skin. 

The third degree of burn is distinguished by the presence of one or 
more patches of a grayish white, yellowish, or brownish color, repre- 
senting the dead portion of the papillary layer of the skin ; the 
vesicles covering these patches are filled with a brownish, lactescent, 



288 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

or sanguineous serum, while those on the erythematous part of the 
burn arc transparent. If the discolored patches be lightly touched, 
they are found to be insensible, but if they be pressed with any force 
so as to act upon the parts below, the pain is considerable. The pain 
attending this form of burn is always more severe than that of any 
other kind, in consequence of the seat of mischief being the most 
sensitive part of that organ of acute sensation, the skin ; and it lasts 
for one or two days. In three or four days after the burn, the pain, 
which had ceased, is suddenly renewed, suppuration becomes active, 
and the process of separation, by which the dead is to be removed from 
the living tissues, is established. When the ulceration finally heals, 
it leaves behind it a cicatrix, which is white from the loss of the vascu- 
lar layer of the skin, and more or less fibrous and areolated, accord- 
ing to the depth in the corium, to which the burn had extended. 

In the fourth degree of burn the heat is prolonged, until the whole 
thickness of the skin is burnt through ; at first, the surface is dried by 
the contact of the burning body, and the process of drying is continued 
until the skin itself becomes inflammable, and burns in the heat which 
is applied to it. The pain is excessive while the burning lasts, but as 
soon as it is over, there is a cessation of pain, on account of the entire 
destruction of vitality of the injured part. The eschar is dark gray, 
or blackish and yellowish in color, hard, dry, and insensible ; and 
being shrunk by the heat, draws the skin around it into puckers and 
folds, the latter presenting the erythematous and vesicated forms of 
burn. In scald the eschar is soft, pulpy, and gray. 

At the end of three or four days the process of separation of the 
slough commences, being ushered in by severe and acute pains, and 
by the appearance of a broad erythematous band around the eschar. 
The eschar is loosened by an abundant suppuration, and at the end of 
from fifteen to twenty days is thrown off, leaving a deep ulcer, which 
heals up quickly by granulation. The cicatrix which follows the 
healing of the ulcer is indelible, and often a cause of considerable de- 
formity, on account of the contraction which ensues and the adhesion 
of parts accidentally drawn together. It is well remarked by Dupuy- 
tren, that this contraction rarely takes place on the dorsal side of the 
trunk of the body and limbs, in consequence of the constant and 
powerful action of the flexor muscles. In the neck, arms, hands, and 
feet it is less uncommon. 

The fifth and sixth degrees of burn are simply more complete than 
the preceding, involving a greater depth of tissues in destruction. 
They result either from a longer continuance or from a higher degree 
of heat. In the latter case the effects may be so rapid as hardly to 
occasion pain. Roche, Sanson, and Begin, report the case of a young 
man who, having placed his foot in a gutter through which molten 
metal was about to flow, was overtaken by the stream of liquid fire, 
and on withdrawing his limb, found his foot and the lower part of the 
leg gone, without having experienced any sensation of pain. 

The constitutional symptoms of gangrenous burn differ from those 
accompanying the erythematous and vesicated burn, chiefly by the 
addition of certain secondary phenomena, which accompany the sepa- 



AMBUSTIO: BURNS AND SCALDS. 289 

ration and elimination of the dead portions of the skin. Thus, in a 
burn, we have to consider two groups of symptoms, primary and 
secondary, the primary symptoms being those which result from the 
shock done to the constitution; the secondary symptoms those which 
are concerned in the reparation of the injury. 

The primary symptoms are, cerebral and spinal irritation, conges- 
tion of the cerebral, thoracic, and abdominal organs, and internal he- 
morrhagic effusions. 

The immediate agent in the excitation of the brain and spinal cord 
is pain, and the pain is sometimes so great as to destroy life at once, 
particularly in children and persons of sensitive temperament. Du- 
puytren was of opinion that pain might exhaust the nervous sys- 
tem of its vital spirits, just as the heart and vascular system are ex- 
hausted by excessive hemorrhage, and he distinguished these cases as 
instances of mort par exces de douleur. At other times, the pain, by 
exciting violently the brain and nervous system, may cause an imme- 
diate and instantaneous congestion of the whole of the internal 
organs of the body, the brain, the lungs and heart, the alimentary 
canal, with its cavities and glands. This state, in fact, is met with 
in persons who have been rescued dead from a conflagration, or, 
although living at the moment, have died immediately afterwards; 
the brain, heart, lungs, and mucous membrane have been found 
gorged with blood, extravasation has occurred in many places, par- 
ticularly in the mucous membrane, and blood has been effused by 
exhalation into the cavities of the mucous and serous membranes. 
This state' of congestion is termed primary, from its occurrence at the 
time of the injury, and to distinguish it from those phenomena which 
are the consequence of reaction, secondary phenomena. The effect of 
violent congestion of the heart is to arrest the function of that organ, 
and cause immediate death. 

In every case of burn, therefore, of any extent, we have to deal 
with the shock to the nervous system, which may, as we have seen, 
exhaust life at once ; or by excitement and violent stimulation of the 
nervous system, cause a rapid and serious congestion of all the organs 
of the body. In the one case we may find extreme prostration of 
muscular power, mental stupor, cold skin and extremities; small 
quick pulse, and slow respiration. In the other case we may have 
excessive agitation, mental excitement, restlessness, sleeplessness, 
convulsions, and a high degree of fever. In both, congestion of inter- 
nal organs may occur, and both may be speedily fatal, or may give 
way to more favorable symptoms; in the one reaction, in the other 
calm and sleep. 

The secondary symptoms of burn, or those which belong to the 
reparative period, are such as accompany the development of inflam- 
mation and suppuration for the removal of the injured parts, and the 
exhaustion which necessarily follows the suppurative process. Ac- 
cording to Dupuytren, there are four epochs of danger in the course 
of a burn : firstly, the period of irritation ; secondly, that of inflam- 
mation; thirdly, that of suppuration ; and fourthly, that of exhaustion. 
The inflammatory reaction may be so severe as to give rise to a state 

19 



290 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

of general fever; the patient has a frequent and full pulse, the skin 
is hot and parched, the tongue red and dry; there is thirst, nausea, 
and vomiting, and every indication of gastro-intestinal irritation, 
frequently complicated with cerebral and pulmonary congestion. The 
limits of this period are from the third to the ninth day. After 
suppuration is established, serious internal lesions may result from 
the absorption of pus; and during this period the internal congestions 
which have already taken place may undergo further morbid changes, 
and result in ulcerations, perforation of the duodenum, destruction 
of tissues, and other dangerous consequences; while the period of 
exhaustion, from a long-continued drain on the powers of the consti- 
tution, is also a stage of considerable danger and anxiety. Besides 
all these unfavorable conditions, the patient may be the subject of 
erysipelas, or phlegmonous erysipelas, at any period of the progress of 
the injury. 

My friend, Mr. Grantham, of Crayford, in Kent, has published a 
remarkable case of burn, in which several of the points of difficulty 
and danger here laid down are illustrated. 1 The patient was a boy, 
about seventeen years of age, who was burned by fireworks exploding 
in his pockets; the burn occupied nearly the whole of the trunk of 
the body, destroying the entire thickness of the skin, and offered an 
extent of six hundred superficial inches, equal to four feet twenty- 
four inches of surface; and was a quarter of an inch in depth. The 
period of depression lasted forty-eight hours, being marked by coma, 
a rapid fluttering pulse, and coldness of surface; and reaction was 
accompanied by an excitable state of the brain, a pulse ranging 
between 150 and 200 beats in the minute, and an irritable stomach, 
that refused to retain fluids of any kind. This state continued for 
a period of four days, and was succeeded for twenty-five days by a 
]<>\s typhoid form of fever. The fever then abated, and he gradually 
improved until the seventh month, when he was attacked with bron- 
chitis, accompanied with sanguineous expectoration. At the end of 
eighteen months he was able to walk a short distance, and then had a 
violent attack of erysipelas, and was not finally cured until nearly five 
years after the accident. 

The treatment pursued during the period of depression, was opium, 
brandy, beef-tea with arrowroot, artificial heat by means of hot bottles 
to restore the warmth of the body, and the application of spirits of 
turpentine to the edges of the burn. During the period of reaction, 
while the stomach was so irritable as to reject all fluids, beef-tea was 
exhibited in the form of enema; and shortly afterwards, bicarbonate 
of soda and compound spirits of ammonia were given in drachm doses 
by the mouth, as the stomach would bear them. During the con- 
tinuance of the typhoid fever he was nourished with beef-tea, mutton 
broth, and port wine; and as the typhoid symptoms abated, was plen- 
tifully supplied with milk, taking on an average six pints within twenty- 
four hours. 

1 Facte and Observations in Medicine and Surgery: the gleanings often years of active 
general practice, &c. Churcliill. 1844. 



AMBUSTIO: BURNS AND SCALDS. 291 

The local treatment consisted of linseed poultices with yeast ; dusting 
the separating parts with powdered bark and chalk ; and when the 
typhoid fever had abated, dressing the ulcers with spermaceti spread 
on lint, covering the lint with cotton-wool, and then applying a roller. 

The attack of erysipelas, which occurred at the eighteenth month, 
had the effect of enlarging the dimensions of the ulcer from forty-five 
to one hundred and fifty inches ; recourse was again had to opium in 
small doses, and nitric acid ; and after the subsidence of the erysipelas, 
the healing progressed with rapidity. By the end of the second year 
the ulcer was reduced in size to twelve inches ; and by the end of the 
thii'd year to one inch ; it now remains "in a passive state for the 
space of a year and a half" before it finally healed. 

During the whole process, Mr. Grantham remarks that there was a 
greater or less "tendency to congestion of the brain," which was 
" relieved by small bleedings, occasional saline aperients, and a strict 
attention to diet, especially in reference to the use of stimulants, which 
never appeared to be indicated." 

Of the cause and diagnosis of burn nothing need be said more than 
has been already related. The prognosis of the burn is a question, 
into the answer to which a number of considerations enter — namely, 
its extent, both in breadth and depth ; its seat, whether upon the 
trunk of the body, the face, neck, or limbs ; the age of the patient, his 
constitution and temperament ; and the nature of the agent causing 
the burn, whether fluid or solid, whether limpid or dense ; whether of 
a moderate or excessive degree of temperature ; whether in the form 
of steam or flame ; whether combined with mephitic vapors ; and 
whether instantaneous in its application to the skin, such as the explo- 
sion of gas or gunpowder, or prolonged. Again, the question of prog- 
Dosia not only involves the consideration of the primary and secondary 
dangers attendant on burn, but also, if the prognosis be favorable, 
the nature of the cure ; burns of the first, second, and third degree 
produce no deformity, but burns of the fourth degree are often followed 
by considerable deformity, from the contraction of the surrounding 
skin, which ensues during healing, and the adhesion of parts (during 
the granulating period) that ought to be kept separate. Thus, in burns 
of the neck, the chin is liable to be drawn towards the chest, or to one 
or other shoulder ; and in burns of the hands and feet, the fingers and 
tors may be drawn out of their proper axes, and the joints dislocated. 
All tilings considered, therefore, the prognosis of burns is uncertain. 

TREATMENT. — The management of burns and scalds presents two 
indications for immediate attention ; firstly, to relieve pain, calm the 
nervous system, and restore the circulation to its normal standard; 
secondly, by local applications, to supply a covering of defence, which 
shall be BOOthing and .agreeable to the injured part. 

The first of these indications is to be accomplished by means of 
opium conjoined with warm brandy and water, the dose to be propor- 
tioned to tlie severity of the suffering, and its repetition regulated by 
the continuance of the symptoms. The opiate to be preferred is the 
liquor opii sedativus, of which the dose may be fifteen minims; or in 
the absence of the sedative solution of opium, the tinctura camphorse 



292 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

composita, two drachms ; or tinctura opii, half a drachm. The seda- 
tive may be repeated at the end of two or three hours, if necessary ; 
and the brandy-and-water as often as ma) r be requisite ; bearing in 
mind that the stage of depression will, if the patient survive, be fol- 
lowed by a stage of reaction, when an opposite method of treatment 
will be required. 

The best local application, where the cuticle is'unbroken, is flour, 
which possesses the additional advantage of being always at hand ; it 
should be thickly dusted over the burnt or scalded part by means of 
the dredger : a layer of wadding or cotton-wool should be placed next, 
and then a bandage, lightly but firmly applied to prevent friction. 
The purpose of the local application is threefold : namely, to cool the 
heated skin ; to exclude the atmospheric air, which is always an irri- 
tant to an inflamed surface; and to preserve the part in a state of re- 
pose and defend it from pressure. Hence all meddling is objectionable, 
and the part once secured should not be disturbed, even although the 
pain increase after the dressing has been applied. 

When blisters are formed they may be pricked with the point of a 
needle, to prevent them from bursting and causing excoriations ; and 
where excoriations exist, they may be covered with a liniment of 
olive oil and white of eggs (pars * ad 2 ), or with the benzoated oint- 
ment of oxide of zinc. It sometimes happens, that when the flour 
has been on for some time, and particularly where there has been any 
serous effusion from the vesicles, that it cakes, and becomes hard and 
uncomfortable to the skin. In this case, the surface, and particularly 
the crevices of the dried crust, should be moistened with the liniment 
mentioned above ; or with a liniment of lime-water and olive oil ; or 
lime-water and linseed oil (equal parts), and the whole covered with 
lint, spread with the benzoated ointment of oxide of zinc, and after- 
wards some cotton-wool, and a light bandage. 

In the third and fourth degrees of burn, where a portion of the 
skin has been killed by the heat, and the cuticle is excoriated to a 
greater or less extent, while in the circumference, the injured part 
presents the erythematous and vesicated degrees, the denuded part 
may be pencilled with either of the liniments already mentioned, 
while the circumference is dredged with flour. Then the denuded 
part should be covered with lint spread with zinc ointment. Some- 
times, with the idea of bringing back the vitality of the part killed by 
the heat, or of preventing parts which were merely weakened from 
falling into the state of gangrene, the stimulant properties of turpen- 
tine are added to the remedy. This maybe effected by rubbing down 
a little common turpentine with either of the above liniments ; or the 
pari ma v be dressed with the unguentum elemi compositum, after the 
application of the simple liniment to the skin. It was upon this prin- 
ciple thai Mr. Grantham, in the case above narrated, bathed the edges 
of the injured part with spirits of turpentine. 

Whenever a burn or scald has been received on a covered part of 
the body, the clothes should be removed, and with extreme care, lest 
the cuticle be rubbed off, and the part excoriated; and the part 
being completely exposed to view r , the flour dredger should be inime- 



AMBUSTIO: BURNS AND SCALDS. 293 

diately brought into play. It has been recommended immediately 
a burn occurs, that the part should be plunged in cold water, and kept 
there until the burning pain has subsided ; this, however, can only be 
done where a part of a limb is concerned; and there can be no objection 
to it as a preparation for the flour application. In burns or scalds of 
small extent, a poultice of the pulp of raw potatoes, or a poultice of 
soap, are favorite popular remedies, and perfectly innocent; but are 
neither so pleasant nor so convenient as the flour dredging. Again, 
when the shock to the system has produced a chilled state to the 
surface, the moist and cold applications would be objectionable, as 
tending to aggravate that state. Fabricius and Sennertus used the 
pulp of raw onions, in combination with oil, soap, and salt ; or oil, 
white of egg, and salt, when the skin was unbroken, but omitted the 
onion and the salt where the surface was vesicated. A liniment com- 
posed of the whites of two eggs, two ounces of olive oil, and one of 
rosewater, was esteemed a great secret in the time of Ferrarius, by 
whom it was applied by means of a piece of linen rag ; the rag being 
kept on the skin, and saturated twice or thrice a day with more of 
the liniment. The green parts of the elder were also much used, made 
into an ointment with fresh butter. 

In illustration of the principle of securing an impermeable covering 
to the burn, and leaving it undisturbed, a principle which I have 
already advocated in the treatment of eczema, I may mention the 
remark of a house-surgeon of a London hospital, emulous of distin- 
guishing himself during his week of service. I met him one day at 
the corner of a street, when he said : " I never left the hospital for an 
entire week, and got nothing but a cut finger and six burns. The 
burns all died, with the exception of one, and he was the worst ; he 
had tumbled into a vat of boiling soap. When he came to the 
hospital he was covered with the soap, which had congealed on the 
skin, and we could not remove it without bringing off the skin at the 
same time. We could do nothing for him, so we left him alone; and 
he lived." This brief commentary on a week's idleness contains 
volumes for reflection and thought. The poor man who fell into the 
soap-maker's vat found the wound and the antidote at the same 
moment, he came out surgically dressed ; the injury was immediately 
sealed up by the hardening soap, the air was instantaneously excluded; 
and although badly scalded, and having one of the most dangerous ot 
burns, that of a large surface, the whole surface of his body in fact, he 
lived. Accident has given us here a lesson, an example, for imitation. 

In burns of the third and fourth degree, where we look for inflam- 
matory reaction and subsequent suppuration for the removal of an 
eschar or slough, inflammation may sometimes run too high; and we 
may find it necessary to subdue the inflammatory action by means of 
evaporating lotions, which maybe applied externally to the immediate 
dressing. On the other hand, it happens most frequently that gentle 
stimulation is necessary, to quicken the flagging powers of the skin, 
and hasten suppuration, and the separation of the dead parts. In the 
latter case we find a useful auxiliary in lotions of the chloride of lime, 
(5i ad 5viij); in the compound ointment of elemi, or in the yellow 



294 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

basilicon, the unguentum resinre. Daniel Turner remarks, in reference 
to the manipulation of burns, that, "at this, if at any time, the lady's 
hand is required;" and, in reference to the class of burns now under 
consideration, he observes, "I seldom found occasion to use other 
than my unguentum de lapide calaminari from first to last, which is 
anodyne, digests, incarns, and cicatrizeth to admiration ;" and he 
further lauds the uses of the oxide of zinc, under the magnificent 
name of Diapompholigos. 

After the period of depression, -which may last for twenty-four or 
forty-eight hours, is past, and reaction is established, we may have to 
treat constitutionally those conditions of the general system which 
accompany inflammation and congestion of internal organs. We 
must have recourse to mild aperients, effervescent salines, and an 
antiphlogistic regimen ; we may be required to abstract blood generally 
and locally, and contend with the various congestions as they show 
themselves. In Mr. Grantham's case, it will be seen that he had to 
combat in succession typhus fever, bronchitis with sanguineous ex- 
pectoration, erysipelas, and symptoms of congestion of the brain. In 
the suppurative stage of the injury, where the powers of the consti- 
tution are exhausted by a long-continued drain, it will be found 
necessary to have recourse to a generous diet and tonics. 

Professor Hebra, of Vienna, has recently suggested for the treat- 
ment of burns and scalds, as also for certain eruptions of the skin, a 
perpetual warm bath; and he has deposited at the International Exhi- 
bition of 1862 his apparatus for that purpose. He mentions the case 
of a washerwoman, aged thirty-eight, "extensively burnt all over the 
body, dermatitis ambustionis escharotica," who was kept in the bath 
"during twenty-one days, or 504 hours, without interruption, and 
left it perfectly healed of her sores." And another, of a man twenty 
years old, who had received a severe burn of his lower limbs from 
falling into a lime-pit ; he was placed in the bath apparatus, and left 
there for twenty-eight days, or 672 hours, until the sores were perfectly 
healed ; the burn in this case had destroyed the vitality of the skin 
completely, and it fell away from the parts beneath in charred masses. 
He also gives the case of a boy suffering under chronic pemphigus, 
who "was kept for 100 days, or 2400 hours, in the warm bath appa- 
ratus, and left it only when all symptoms of the disease had dis- 
appeared." On a relapse taking place some months afterwards, the 
boy was again placed in the bath at his own repeatedly expressed 
desire. 

Professor Hebra's bath apparatus is a box, 6 feet long by 3 wide, 
made of wood, and lined with copper or zinc. Inside the box is an 
iron frame or stretcher, and upon the stretcher is placed the bed, 
covered with a blanket, and furnished with a horse-hair bolster; while 
at two feet distance from the head of the bed is a back support, moving 
on a hinge, and admitting of being fixed by means of a simple piece 
of rack-work, at any angle that may be agreeable to the patient; 
moreover, at each extremity, the bed is suspended by two bands, 
which work upon rollers attached to the margin of the box, and 
enable the attendant to raise or depress the bed, and so alter the posi- 






GELATIO: FROSTBITE. 295 

tion of the patient without otherwise moving him. The supply of 
water to the bath is obtained from a copper boiler placed above the 
level of the bed, and near its head; the water flowing into the bath 
enters at the bottom, and the escape pipe leaves it at the water level ; 
" the stream is kept constantly running, and thus all impurities are 
rapidly washed away from the surface." If it be desired to keep the 
face continually wet, special small tubes, with different roses affixed 
to the boiler, are provided for the purpose. 

The water of the boiler is intended merely to secure a current in 
the bath ; the bath is filled daily independently of the boiler with water 
of the required heat, ranging from 90° to 100° of Fahrenheit. When 
the patient is properly placed and the bath filled, the apparatus is 
closed with a wooden cover, and over this a woollen blanket is spread ; 
and if it be required to cover the head as well as the body, a small 
frame constructed of hoops answers the purpose. 

Of the practical results of the process, as well as its theory, "the 
application is too novel at present to permit of conclusive judgment." 
The apparatus "requires continual attendance," to keep the tempera- 
ture uniform and to secure the safety of the patient, "although there 
exists not the slightest danger that the patient, in sleeping, may run 
the risk of being drowned." During the experiments heretofore tried, 
nothing has occurred to suggest the apprehension of such a danger. 

GELATIO. 

Frostbite. Pernio. Chilblain. Kibe. 

Cold in great severity, or applied for a long time to the surface of 
the body, or acting upon a sensitive constitution, produces local 
insensibility, and may proceed to the extent of actual freezing of the 
part affected. The first action of cold is therefore upon the nerves of 
the body, and it attacks primarily those parts which are the most 
distant from the centres of innervation and circulation, namely, the 
feet, the hands, the ears, nose, chin, cheeks, and the surface of the 
body, extending from the surface inwardly to the more central organs. 
With the insensibility or numbness of the chilled part there is dimi- 
nished or arrested circulation, producing paleness and contraction or 
diminution of size, and there is also loss of motion, or stiffness. The 
arrest of circulation and loss of power of motion are, however, con- 
secutive to and governed by the loss of sensation. 

Gelatio naturally presents every degree of severity, from the mere 
chilling of a very limited extent of the surface of the skin, consti- 
tuting chilblain, to positive freezing and death of a part of the body. 
In the one case there is a mere suspension of vitality, in the other a 
state of complete death. So long as the state of chill is progressive 
or persistent at the same point, the signs of gelatio are those already 
indicated, namely, numbness or insensibility, paleness, reduced size, 
and immobility ; but when the temperature undergoes a degree of 
elevation, however slight, such as that which causes a thaw, then a 
new series of phenomena are presented by the congelated part, 
phenomena which are comprehended by the term reaction. Sensation 



296 DISEASES FROM SPECIAL EXTERNAL CAUSES. 

returns, but the sensation is of a painful kind ; a teasing itching, 
where the chill is superficial;, and a burning, tingling, or severe and 
acute pains, where the chill has reached the deeper nerves. Circula- 
tion also returns ; the part becomes red, swollen, and hot, in the first 
stage of reaction, blue and livid at a later period; in other words, a 
state of inflammation of the skin, or erythema, takes the place of the 
previously pale and benumbed condition of the part. 

But where the cold has been so severe or so long continued as to 
destroy the life of the part, that part retains the insensibility, the 
coldness, and the paleness of death ; while the living parts alone 
take on the characters just mentioned — namely, the redness, the heat, 
the swelling, and the pain. The redness of the skin terminates by 
an abrupt line, and at this line it is, the line of demarcation, as it is 
termed in surgical language, that the actions which result in the 
separation of the living part from the dead take place. The dead 
part remains contracted and shrivelled, it becomes dry and dark 
colored, finally Mack ; and ultimately is thrown oft', if it be superficial, 
or drops off, if it be a part of a limb. 

These being the general effects of cold upon the living body, we 
may now turn our attention to those slighter degrees of chill so 
common and so troublesome amongst children and adults of weakly 
powers of innervation and circulation, during the winter season ; those 
minor troubles which go by the names of perniones, chilblains, and 
kibes. 

Chilblains, like burns, admit of division into three groups, which 
represent so many degrees of severity of the affection : they are, the 
erythematous chilblain ; vesicated chilblain ; and gangrenous chilblain. 

The erythematous chilblain [erythema a gelu), originating in 
the lowest degree of cold applied to the skin, is not discoverable until 
the stage of reaction is commenced. A child may have been exposed 
to the cold during the day, and in the evening returns to a warm 
room, and a seat near the fire. Then for the first time the chilblain 
declares its presence, generally on the feet, on the heels or on the 
toes, or on the hands, by itching and tingling ; and if the part be 
examined, it is found to be red and swollen. The itching is incessant 
and tormenting, and continues until sleep overtakes the little victim. 
In the morning, or after a few days, the chilblain has a bluish and 
livid appearance, resulting from the establishment of a permanent 
congestion of the part, dilatation of the capillaries, and retardation of 
the circulation ; the retarded circulation allowing time for the change 
in the blood from its arterial to its venous character. In this way 
and under this form the chilblain may be perpetuated during the 
continuance of the cold weather, fresh chilblains appearing from time 
to time, giving rise to swelling and tenderness of the feet, which 
prevent the little sufferer from walking without pain, and exciting 
fresh attacks of itching every time an alternation of temperature 
from cold to warm occurs. As already observed, the chilblains may 
seize upon the lobes of the ears, upon the ears themselves, and also upon 
the nose, or the prominent parts of the face. 

The vesicated chilblain, orbroken chilblain, is either an aggrava- 



GELATIO: FROSTBITE. 297 

tion of the preceding, or the result of a greater degree of cold. During 
the continuance of the cold, it may be accompanied with a greater or 
less degree of numbness; and on the change to a more elevated 
temperature, the pruritus, the swelling, and the congestion are more 
considerable. The vesicated chilblain, moreover, has a purplish, livid 
tint, and the cuticle gradually separates by effusion beneath it, and 
forms a vesicle or bulla of variable extent. The contents of the 
vesicle are a sanguinolent serum, and the surface which is exposed 
on its bursting is either livid or variously mottled with red, blue, or 
gray, the gray portion indicating the commencement of a slough. 
Besides heat, tingling, and itching, the vesicated chilblain is attended 
with considerable pain, it ulcerates to a greater or less extent, and 
prevents the child from walking. Although not dangerous, broken 
chilblains are very painful and troublesome, often lasting the greater 
part of the cold weather. 

The gangrenous chilblain is rather a frostbite than a mere chill 
of the surface of the skin, like the true chilblain. The vitality of 
the affected part is destroyed by the cold^and a state of gangrene, 
followed by the separation of a slough, ensues. The two former 
degrees of chill are unaccompanied by constitutional symptoms*; but the 
frostbite or gangrenous chilblain is often associated with symptoms of 
general prostration and congestion of the vital organs, particularly of 
the brain, and sometimes terminates fatally. , 

Treatment. — The treatment of gelatio and chilblain is to restore 
the innervation and circulation of the part, and to effect this resto- 
ration gradually. If reaction occur rapidly, and an active circulation 
be set up in the tissues lowered in their vitality by the effects of the 
cold, inflammation and probably death of the chilled structures will 
ensue; the object of treatment is, therefore, to bring about a return of 
sensibility and circulation in the slowest manner possible. To this 
end the patient should be placed in a cold room, and frictions made 
on the part with the hand. If the part be frozen, snow or cold water' 
may be rubbed upon it, to thaw the frozen tissues by degrees; then 
the hand alone may be used, with a little starch powder, to prevent 
attrition, and guard against the too great heat of the hand; then some 
mildly stimulating liniment may be used; and, finally, the part may 
be enveloped in cotton-wool or flannel. 

With a common erythematous chilblain, all these precautions are 
unnecessary, but the general principle of management should be the 
same. Frictions with starch powder, frictions with mild liniments, 
then the use of stronger stimulants; and all with the view of bringing 
back the normal circulation of the part, and restoring its tone, avoiding 
always, and as much as possible, approach to the fire. One of the 
most useful remedies for the above purpose is a liniment composed of 
the white and yelk of two eggs, two ounces of spirits of turpentine, 
and two ounces of distilled vinegar, well shaken together. This lini- 
ment may be lowered in strength, if thought desirable, by more vinegar; 
or it may be Increased in power and made more anodyne by the addi- 
tion of laudanum, camphor, or chloroform; or it may be rendered 
more stimulating by the addition of ammonia. If turpentine be ob- 



298 DISEASES FROM SPECIAL INTERNAL CAUSES/ 

jected to, a liniment of camphor, ammonia, and laudanum (two parts 
of camphor liniment to one of liquor ammonia and one of laudanum), 
may be preferred. Sir Henry Halford was wont to prescribe soap 
liniment with tincture lyttae, six parts of the former to one of the lat- 
ter. Dr. Turnbull recommended a tincture of cayenne 1 to be rubbed 
on the chilblain by means of a sponge, until tingling and a feeling of 
electricity were occasioned in the part. Rayer suggests a strong so- 
lution (5j ad 5xvj) of alum ; and Dr. Balfour, of the Royal Military 
Asylum at Chelsea, uses, amongst the numerous boys under his care, 
a mixture of equal parts of compound tincture of iodine and liquor 
ammonise, which he causes to be painted on the chilblains twice in 
the day. 

The vesicated and ulcerated chilblain are to be treated, according 
to their state of activity or indolence, with the water-dressing applied 
by means of Alison's impermeable lamb-skin; the benzoated ointment 
of oxide of zinc; the calamine ointment; or some more stimulating 
remedy, such as an ointment of Peruvian balsam (5j ad §j), the un- 
guentum elemi, or ceratum resinae. In the broken state of chilblains, 
Dr. Balfour prescribes, with great success, an ointment composed of 
equal parts of ceratum resinae and spirits of turpentine. 

The gangrenous chilblain and frostbite are to be treated, after the 
restoration of circulation in the sound parts, in the same manner as 
sloughing and gangrene resulting from burns. 



CHAPTER XIII. 

DISEASES ARISING FROM SPECIAL INTERNAL CAUSES. 

TnE diseases assembled under this head, arising from specific causes, 
those causes being internal and obscure, and presenting characters in 
common with each other, namely, prominence and permanence, are 
five in number, namely, 

Lepra, Scrofuloderma, 

Lupus, Kelis, 

Elephantiasis. 

Of these diseases, the least degree of prominence is met with in 
Lepra, which is especially characterized by the development on its 
surface of a scaly covering; hence, lepra. is the type of the order 
8QUAM2E of Willan. The other four, on account of their prominence, 
belong to the order tubercula of Willan. The whole of these dis- 
eases are remarkable for their chronic character and obstinate resist- 
ance of treatment. 

In previous editions of this book lepra was associated with two other 

1 R. — Capsici contusi, 5J ; spiritus vini rectificati, t ^iij; macerate for a week, and 
strain. 



DISEASES FROM SPECIAL INTERNAL CAUSES. 299 

affections, namely, psoriasis and pitjaiasis, under the general head of 
"squamous inflammation of the derma;" but longer experience and 
more careful investigation have convinced me that lepra should stand 
alone, the term psoriasis, which has been used indiscriminately for varie- 
ties of lepra, and for that kind of chronic thickening of the skin which 
often succeeds to eczema and lichen, should be applied to the latter 
only ; and that pityriasis, which bears no relation to lepra whatever, 
but is a mere chronic erythema of the skin, accompanied with furfu- 
raceous desquamation of the epidermis, should be carried back to the 
erythematous group. In fact, lepra or not lepra ? will in future be 
the question to be determined by diagnosis, and a vast quantity of 
confusion will be spared to the student of dermatology ; we may then 
hear of the cure of psoriasis, a comparatively easily curable complaint, 
without feeling the doubts which rise to the mind when a lepra is 
believed to be the disease in question ; and by means which, in truth, 
are not in the least calculated to make an impression on lepra. 

A glance at the derivation of the term psoriasis, supplies an addi- 
tional reason for discarding it from its connection with lepra. Psora 
is derived from the Hebrew word tsorat, signifying venom or malig- 
nity, and is a generic term for the worst forms of the leprosy of the 
Jews. The Greeks, in their translation of the Hebrew writings, gave 
to the disease which tsorat represented, a word of their own, namely, 
Asxpa, and dispensed with the term tsorat altogether, or so entirely mis- 
appropriated it, that it lost its original signification, and " wandered 
in search of a meaning." It has since " had at different times - , and by 
different persons, various meanings attributed to it ; being sometimes 
used to express scaly eruptions generally, sometimes the scales of 
leprosy," 1 then the scaly state of the. skin which accompanies scabies 
(psora), and lastly, the scaly stage of chronic eczema. With the latter 
meaning, the word psora, with its altered termination, making it pso- 
riasis, is used by Willan, Bateman, and Mason Good. Tsorat and 
psora are also the origin of our own popular expression, sore. 

The cause of the present group of diseases is obscure; it is, probably, 
some poison present in the blood, engendered by conditions either ex- 
ternal to the body, or within the economy itself. Numerous observa- 
tion.- have led me to the conclusion that lepra originates in the syphi- 
litic poison, the poison being modified by transmission through one 
or more generations. Lupus, in some instances, is clearly referable 
to the poison of syphilis; in others it seems to appertain to an affection 
equally mysterious, namely, scrofula; and scrofula, I believe to derive 
one of its sources from syphilis. Kelis is allied with scrofuloderma, 
often making its appearance on the cicatrices of scrofulous sores, or in 
children suffering under scrofulous affections. The cause of Elephan- 
tiasis is as much a mystery, as deeply plunged in obscurity at the 
present day as it was before the commencement of the Christian era, 
when it made its first outbreak among the inhabitants of the banks of 
the Nile. From Egypt it travelled through Syria to Greece; from 
Greece it pursued a westerly direction through Europe. After ex- 

1 Mason Good. 



300 DISEASES FROM SPECIAL INTERNAL CAUSES. 

hausting itself in England, it moved northward into Scotland, from 
Scotland to the islands of Orkney and Shetland ; and at the present 
moment rages with severity in Iceland, and on the coasts of Norway 
and SAveden. 

LEPRA. 

Syn. — Common dry tetter. Circular dry tetter. Diffused dry tetter. 
European Leprosy. AlpJios. Lepidosis lepriasis. Dartre squamme use. 
Dartre furfur acee arrondie., Herpes furfur aceus circinatus. Herpes 
gquamosus. Aussatz, SchuppenfLechte. 

Lepra (Plate XII.) is a non-contagious and chronic inflammation of 
the derma, consisting in the eruption, on various parts of the body, 
of raised and circular patches, which are speedily covered by thin, 
semi-transparent scales of white and morbid epidermis. The patches 
are prominent around their circumference, and somewhat depressed 
in the centre ; they increase by the extension of their periphery, 
while the central area gradually returns to the natural state. During 
the progress of the patches the scales are often thrown off, and 
replaced by successive formations. The local disorder is unaccom- 
panied by constitutional symptoms; it is most strongly marked in 
the neighborhood of the knee and elbow joints, where it frequently 
forms continuous patches of large size (Plate XII., G.) and endures 
for a considerable length of time, sometimes recurring at particular 
periods for several years, and lasting for several months at each recur- 
rence. 

The patches of lepra begin by small flat tubercles, of a brickdust 
red color, and very slightly raised above the level of the surrounding 
skin. Like the pimples of lichen, they are developed around the 
pores of the skin, and at their first appearance are only twice the size 
of the erected pores of cutis anserina ; the diameter of the latter, 
when round, being half a line ; and when elliptical, as they commonly 
are, half a line in breadth, and three-quarters of a line in length. 
Starting with a size of one line in diameter, the tubercles of lepra soon 
attain their mature development, and measure two lines in breadth. 
The pathological element of lepra is, then, a small 'flat tubercle, very 
little larger than the papule of lichen, and occupying, like the latter, 
the mouth of a perspiratory tube or cutaneous follicle. 

Having reached its full stage of completion, the leprous tubercle 
may remain stationary, and become capped with its little white scale 
of morbid cuticle, bestowing all its power on the production and 
reproductioD of this scale. More frequently, however, it excites 
around itself a little erythema, and more or less puckering and dis- 
tension of the immediately adjacent epidermis. It is now converted 
into a small patch of from three to four lines in diameter, consisting 
of a central tubercle, and the slight halo of erythema and puckered 
cuticle just described. The eruption sometimes becomes arrested at 
this stage, and constitutes the form of lepra termed lepra guttata ; the 
small slightly-raised patches, with their little white caps, having 
about the diameter and somewhat the appearance of drops of water 



LEPRA. 301 

scattered over the skin. Sometimes the erythema extends a little 
farther into the surrounding derma, and attains a diameter of five or 
six lines. When this occurs, the included pores rise like the first into 
tubercles, and the patch is found to be composed of two, three, four, 
or five tubercles, the integument between the tubercles being erythe- 
matous, and raised above the level of the surrounding skin, although 
not so elevated as the tubercles themselves. A similar result follows 
when two, three, four, or five tubercles occupy adjacent pores at the 
same time ; the patch is composed of a cluster of tubercles, but rarely 
exceeds the diameter of half an inch. 

From this description, it will be seen that lepra guttata is lepra in 
its most elementary form ; the tubercles are dispersed and isolated, 
the presence of a cluster of two, three, or more tubercles being the 
exception and not the rule. In a case of lepra guttata now before me, 
there are about eighty tubercles and patches, scattered over a surface 
as large as my hand ; of this number, about one-third are isolated 
tubercles, from one to two lines in diameter ; one-half are small patches, 
three lines in diameter ; while the remainder are clustered patches, 
varying in size from four lines to six and seven. The function of the 
tubercles and patches is, as it were, consumed in the production and 
reproduction of thickened and morbid epidermis, which is cast from 
time to time in the form of scales, in other words, their action is verti- 
cal and not peripheral. 

We have next to consider the same pathological elements, con- 
joined with a greater energy of growth, and a disposition to peripheral 
as well as to vertical increase. These are the characters which mark 
lepra vulgaris, or, as I propose to name it, from the roundness of figure 
of its patches, and to distinguish it from other forms of lepra, lepra 
circinata. Lepra vulgaris consists of patches of a circular form, 
varying in diameter from half an inch to an inch and a half or two 
inches, the common size being an inch, and composed of a cluster of 
flattened tubercles, having separately a diameter of two lines. The 
patches of lepra vulgaris make their first appearance in a cluster, the 
tubercles attacking adjacent pores, and quickly becoming more or less- 
blended with each other. As they enlarge the patch becomes more 
or less uniform, but a certain unevenness of surface always indicates 
their original composition of separate tubercles. The patch of lepra 
vulgaris enlarges by its circumference, gradually creeping into the 
Bound skin, and exciting as it goes the production of new tubercles, 
and the fusion of these new tubercles into a rounded border of greater 
<>r Less elevation and uniformity. As this peripheral growth proceeds, 
the tubercles in the centre of the patch slowly subside, and after a 
time the skin assumes its normal characters. The patch is now con- 
verted into a ring, of which the dimensions of the area gradually 
increase, while the growth of the bonier continues, invading, as it pro- 
ceeds, ;i greater extent of skin, but rarely exceeding the dimensions of 
an inch and a half or two inches. 

The arrest of growth of the periphery of the patch of lepra vulgaris, 
and the increasing dimensions of its area, constitute the stage of 
dispersion of the eruption ; the border becomes more and more nar- 



302 DISEASES FROM SPECIAL INTERNAL CAUSES. 

rowed as the area enlarges, and before long the ring itself gives way, 
sometimes at one point, sometimes at several, the tubercles having 
subsided, and the skin having resumed its normal appearance. When 
the eruption is seen at this period, that which a few days back was a 
ring is now changed to the figure of the letter (J- or, having yielded 
in two places, it represents two crescents, or may be, having faded 
further, only a single crescent or a part of a crescent. Then, if two 
patches have so increased that when they are converted into rings, the 
two rings come into contact, we have the figure 8, or if both rings 
have given way, one on the one side, the other on the.other, the figure 
is that of an S- Again, if, instead of two rings, three, four, or five, 
variously grouped, have become connected by progressive growth, and 
have lost part or parts of their circles by dispersion, it is clear that a 
variety of curious and grotesque figures may result, one while, re- 
sembling a chain, at another, astrological and necromantic signs. 
These appearances, the mere phenomena of dispersion of the eruption, 
have, to the confusion of dermatographic science, received the name of 
lepra gyrata. The lepra vulgaris of last month is a new species to-day, 
parading the distinction of a separate appellation. 

There are certain regions of the body that belong especially to 
lepra, where lepra frequently begins, where it exists solely in some 
instances, and where it lingers to the last, when it has dispersed every- 
where else ; these regions are the elbows and knees. If there be any 
doubt as to the diagnosis of an eruption, look to the elbows and the 
knees ; if it do not exist there, and has not visited those regions, it 
is not lepra. If a patient in Australia write to his physician in Lon- 
don, as has occurred to myself, that he is troubled with a dry, scaly 
eruption, dispersed over his body, and particularly troublesome on 
his elbows and knees, the diagnosis is unmistakable ; prescribe for 
lepra ; the rule is as certain and as free from exceptions as any other 
general rule depending on natural laws. But the eruption on the 
elbows and the knees presents a peculiarity, which is, that it obeys a 
regional or local law, with regard to increase, and not the specific law 
which governs the eruption in other situations. It invades the whole 
region, constituting a patch of large size and irregular figure, in 
place of the moderate size and circular patch of other parts of the 
body. This peculiarity is more conspicuous at the elbow than at the 
knee. 

Now, if we look into the structure of this broad patch, we shall find 
that, in consequence of its size, it has lost some of the characters of 
the smaller, rounder, and more isolated patches. It is, in fact, an 
extensive cluster of tubercles of uniform size, less closely aggregated 
than in the circular patches, without the rounded border which forms 
the circumference of the latter, consequently without the depressed 
centre ; and when it disperses, subsiding irregularly, the tubercles 
disappearing here and there, without order, and leaving islets of normal 
skin, and frequently yielding last of all at the point of the elbow ; 
although tin- law of peripheral growth is strong in these larger patches 
as it is ;ilso in the smaller, and the margin is not uncommonly the last 
part to disappear. 



LEPRA. 303 

Sometimes lepra assumes this diffused character as its general out- 
break, and entitles itself to the appellation of lepra diffusa. The 
body is covered more or less extensively with patches of large size and 
irregular form, consisting obviously of a large irregular cluster of 
tubercles of uniform size, scattered over the area of the patch, and 
assembled with greater or less order along its margin. There is no 
sinking towards the centre, because the central tubercles persist as 
long as those of the periphery, and the cure of the patch takes place 
by the subsidence of certain of the tubercles here and there, and the 
clearance, as it were, of small spaces of normal skin. It is true, that 
were we to go further into the inquiry, we should find this apparently 
accidental subsidence of the tubercles in the midst of these patches, 
governed by a peripheral law, each group of tubercles obeying the 
same power as that which governs the entire patch ; but this is unne- 
cessary. Now, the form of lepra which I am here describing is that 
to which the term psoriasis has been improperly assigned, and from 
which I shall endeavor to remove it. I have already explained the 
derivation of psoriasis, and shown that its sole "locus standi " is that 
state of chronic thickening of the skin which sometimes follows ery- 
thema, but more frequently lichen agrius and eczema, in which there 
is redness, thickening of derma, and exfoliation of epidermis in scales 
of greater or less magnitude. But this state of skin, which is not 
unfrequently combined with the exudation of an ichorous fluid, is 
totally and entirely distinct from the clusters of tubercles of lepra ; 
tubercles which never give forth discharge of any kind, and whose 
function is the production of scales of a white, porous, morbid epider- 
mis, and not, as in psoriasis, the separation and exfoliation of an 
otherwise healthy cuticle. Again, by viewing lepra and psoriasis in 
their true light, we are enabled to understand how eczema may, by 
long continuance, merge into psoriasis, a most natural declension ; 
but we are not able to comprehend this natural phenomenon, if 
psoriasis is to be considered as synonymous with lepra. 

The lepra diffusa is sometimes very extensive, involving, for example, 
an entire limb, and with its great extent it presents so obstinate a 
character, as to have gained for itself the appellation inveterata. It is 
commonly termed psoriasis inveterata, but for reasons already given I 
think it more correct to name it lepra inveterata ; the thickening of 
the skin in this severe form of the eruption is often so great as almost 
to obliterate the appearance of tubercles ; and the formation of scales 
is often excessive. 

The tubercles of lepra are an hypertrophy of the structure of the 
derma, mid with this general l^pertrophy it is not uncommon to find 
the papillae very considerably enlarged. With hypertrophy of struc- 
ture there Is also an augmentation of function, hence the large accu- 
mulations of morbid epidermis which occur in this disease. If we 
examine the scales of lepra with attention, we find the epidermis of 
-which they arc composed to be whiter than natural, dry, porous, and 
friable, particularly at the circumference, while in the centre of the 
patches they arc frequently dense and horny. If a scale be raised 
with care it will be found closely adherent to the skin at its central 



304 DISEASES FROM SPECIAL INTERNAL CAUSES. 

part, and as this central portion is lifted up, it is found to be pitted 
into numerous foveolte for the reception of the enlarged papilla of the 
derma. The whiteness of leprosy is, therefore, due to an altered 
epidermis, and the degree of whiteness is referable to the greater or 
less degree of thickness of that structure ; sometimes the whiteness is 
dull, at other times metallic and silvery, and always very remarkable. 
This character of lepra has gained for it the Greek appellation Alphas; 
and for the guttated variety the specific designation alphoides. Lepra 
is the Boak of the Hebrew writers, the dull-white leprosy ; so called to 
distinguish it from the Tsorat or Berat lebena, the Beras bejas of the 
Arabians, the Lepra leuce of the Greeks, the bright-white leprosy, or 
true leprosy. It is of lepra that we read in the thirteenth chapter of 
Leviticus, that "if the leprosy have covered all his flesh, he (the priest) 
shall pronounce him clean that hath the plague : it is all turned 
white." 

The varieties of lepra are four principal, namely, guttata, circinata, 
diffusa, and inveterata; and four secondary, two of which are general, 
namely, nigricans and syphilitica, and two local, namely, lepra capitis 
and lepra unguium. In a tabular form they may be arranged as 
follows : 

Lepra guttata vel alphoides, Lepra nigricans, 
" circinata vel vulgaris, " syphilitica, 

" diffusa, " capitis, 

" inveterata, " unguium. 

LEPRA GUTTATA. 

Syn. Lepra alphoides. Psoriasis guttata. Psoriasis disereta. Dartre 
furfuracee arrondie, Alibert. Weisse Aussatz, Germ. 

Lepra guttata 1 (Plate XII., c) occurs in the form of small convex 
and flattened scaly tubercles and spots, raised above the surface, and 
varying in dimensions from one-sixth of an inch to half an inch in 
diameter. In general aspect, the smaller spots resemble a number of 
drops of water sprinkled upon the skin. They are distributed over 
all parts of the body, particularly on the dorsal aspect of the limbs 
and trunk, and upon the scalp and face. The eruption commences by 
small, red, papular elevations or tubercles, upon the summit of each 
of which a small white scale is developed. The papulae advance 
quickly in growth, and the scales become larger and better defined, 
being reproduced as frequently as they are removed. On the decline 
of the eruption, the affected skin retains a reddish and yellowish stain 
for one or two weeks. Sometimes the larger patches fade gradually 
from the centre towards the circumference, and assume the annular 
form presented by lepra vulgaris during its progress towards cure. 

The eruption of lepra alphoides is rarely preceded by symptoms 
indicating constitutional disorder; if such symptoms occur, they are 
relieved by the outbreak of the eruption. The local symptoms, as in 

1 Portraits of Diseases of the Skin, Plato XV., AM, exhibits a good example of lepra 
guttata, under its old and improper name of psoriasis guttata. 



LEPRA. 305 

lepra vulgaris, are a- trifling degree of pruritus when the skin is heated, 
and at night. 

LEPRA CIRCINATA VULGARIS. 

Syn. Lepra vulgaris. Dartre furfuracee arrondie. Herpes furfuraceus 
circinatus, Alibert. 

Lepra circinata 1 (Plate XII., A b) commences by small, smooth, and 
prominent spots of a dull red color, usually in the neighborhood of 
the knee and ankle joints in the lower extremities, and of the elbows 
and wrists in the upper limbs. In the course of a day or two from 
their first appearance, the spots are covered with thin, whitish scales. 
In three or four days they have increased in size, by the extension of 
their circumference, which is raised and red, while the central area 
loses a portion of its redness and becomes depressed, the whole patch 
being covered by a laminated scale of moderate thickness. After 
increasing gradually in this manner to a size varying from that of a 
four-penny piece to a half-crown, the eruption usually becomes sta- 
tionary, excepting about the joints and upon the scalp, where the 
circles run into each other by their periphery, and form a continuous 
patch of large size. These large irregular patches are also produced 
occasionally in other situations. The scales of lepra are remarkable 
for their grayish white and silvery hue, being sometimes almost 
metallic in appearance. They are composed of thin lamellae, which 
gradually increase in size from the centre to the circumference, so as 
to project beyond each other in an imbricated manner, a disposition 
which is marked on the surface of the scale by a series of concentric 
lines. When rubbed off by the attrition of dress, or thrown off 
spontaneously, they leave upon the skin a surface which is of a dull 
red color and smooth, in recent cases ; and rough, papillated, and 
furrowed when the disease has existed for some time. After their fall, 
the thin crusts are speedily reproduced. 

Lepra is rarely accompanied by constitutional symptoms, and is 
attended with very little local inconvenience, the latter not exceeding 
a slight degree of itching on getting warm in bed, or on exposure of 
the body to changes of temperature. When the patches are so exten- 
sive as almost or completely to surround a joint, they are productive 
of some degree of stiffness. The disease is slow in its march, and 
usually continues for years, sometimes for life, rarely getting well 
when left to itself. 

The first patches of lepra appear about the knee or elbow-joint, and 
often symmetrically on the two limbs at the same time. Willan 
indicates a point immediately below the patella as the most frequent 
site of commencement of the disease. Extending from the knee, the 
patches appear in various points upon the leg, as far as the ankle. 
Willan has remarked, as a peculiarity of lepra, that it occurs in the 
situation of a superficial bone, as in the course of the tibia, of the 
crests of the iliac "bones, &c, and less frequently on the muscular 

1 A good example of lepra circinata, iiwlor tlic name of lepra vulgaris, will be found 
among my Portraits of Diseases of the Skin, Plate XIII., T. 



•30b DISEASES FROM SPECIAL INTERNAL CAUSES. 

9 

parts, as upon the calves of the legs. The patches also proceed up- 
wards towards the trunk, invading in their turn the upper parts of the 
limbs and the trunk of the body. Sometimes the disease attacks the 
scalp, and occasionally the pubic region. 

When lepra affects the scalp, it confines itself to the limit of the 
hair, extending for a short distance only upon the neighboring skin. 
In this situation the disease is highly inconvenient, exciting much 
pruritus, and producing an irritation -which is increased by scratching, 
and followed by bleeding and crusts. Nearly the same inconveniences 
attend the affection when it pervades the pubic region, where, in the 
female, it is frequently accompanied with pruritus, pudendi. When 
the ends of the fingers are the seat of lepra, the formation of the nails 
is disturbed ; they are dry, thickened, irregular, and brittle ; more or 
less separated from the matrix, and have a yellowish curdy matter 
deposited beneath them. 

As the patches of lepra decline, the central portion of the area 
resumes its healthy state, and ceases to produce scales. By degrees, 
the scales upon the circumference of the patch become smaller and 
thinner, the prominence of the skin subsides, and the ring breaks at 
one or several points, the remains of the patches returning very 
slowly to the state of the neighboring skin. (Plate XII., D E F.) 

LEPRA DIFFUSA. 

Syn. Psoriasis vulgaris. Psoriasis confluens, Rayer. Diffused 
dry tetter. 

In lepra diffusa 1 (Plate XII., H i) the patches are of large size, very 
irregular in their form, and of variable extent. The surface of the 
patch is of a dull red color, rough, and elevated above the surround- 
ing skin, intersected by deep furrows, which correspond with those of 
the epidermis, and generally fissured by several chaps of considerable 
depth. The patches are surmounted by numerous thin scales of dried 
epidermis, which are continually exfoliating, and giving place to new 
and successive layers. The chaps are dry, and covered by thin epider- 
mal scales; they frequently bleed, but very rarely pour forth any 
secretion. The patches are developed either by a number of small 
tubercles, which run together and form one continuously-affected 
surface ; or by several small patches, which speedily increase in size, 
and coalesce. In either case the patches are two or three weeks before 
they attain their complete growth ; and it frequently happens that the 
eruption assumes the character of small patches over the greater part 
of the body, and of large ones around the joints. 

The eruption presents several degrees of intensity and extent ; it 
may occur as a single patch of small or large size, or there may be 
several ; it may appear upon all parts of the body, but some it would 
seem to select by preference. I have seen the eruption most frequently 
on the fore-arms, or about the elbow and wrist. The duration of lepra 
diffusa is always tedious; in milder cases it continues for several weeks 

1 Portraits of Diseases of the Skin, Plate XIV., V. Lepra diffusa is represented under 
the name of psoriasis vulgaris. 



LEPRA. 307 

or months ; while, in severer examples, it may be intractable for a 
much longer period. 

LEPRA INVETERATA. 

Lepra inveterata 1 (Plate XII., i) is the most severe and obstinate of 
all the forms of scaly tetter, and may be regarded as an intense de- 
gree of lepra diffusa. It extends over a considerable surface, usually 
occupying the entire of the limbs, but sometimes spreading over the 
whole body, with the exception of the palms of the hands, the soles of 
the feet, and the face. The skin in this variety is thickened, con- 
gested, and hot, and there is more or less pruritus, which is increased 
and troublesome during the night. It is, moreover, dry, harsh, stiff, 
deeply fissured by cracks and chaps, and covered with epidermal 
scales, .which are produced and thrown off in abundance. The 
harshness and thickening of the integument are sometimes so great 
as to interfere with the action of the muscles and movements of the 
joints. When the surface is abraded by pressure, by the violent use 
of the nails, or by any other cause, some bleeding takes place, which 
discolors the scaly surface. 

In lepra inveterata of the scalp, the scales collect in great number ; 
and when the nails are affected, they become yellow, thick, and 
irregular ; they are subsequently thrown off, and replaced by shapeless 
crusts. The duration of lepra inveterata is indeterminate ; it usually 
lasts for several years, and in old persons for life. 

LEPRA NIGRICANS. 

Syn. Schwarze Aussatz, Germ. 

Lepra nigricans is a form sometimes assumed by lepra when it 
occurs in persons of a languid and debilitated constitution. The 
figure and distribution of the patches are the same as in common 
lepra, but they are not so large, and the central depression, which 
marks the commencement of a curative process, does not exist. The 
patches, instead of being of a dull red or brickdust color, are bluish 
and livid, and the scales thin, so that the lividity of the surface is seen 
through them. The scales are easily detached, leaving behind a 
tender and frequently an excoriated surface, from which a morbid 
serous fluid, often mixed with blood, is poured out. This secretion 
hardens by degrees into an irregular and friable crust. Lepra nigri- 
cans sometimes affects the scalp. 

Willan observes, that "the lepra nigricans affects soldiers, sailors, 
scullermen, stage-coachmen, butchers, brewers, laborers, and others 
whose occupations are attended with much fatigue, and expose them 
to cold and damp, and to a precarious or improper mode of diet. 
Women habituated to poor living and constant hard labor are also 
liable to this disease. 

Lepra syphilitica. — Lepra syphilitica will be treated of in the 
chapter on syphilitic eruptions. 

1 Portraits of Diseases of the Skin, Plate XVI., AO. Lepra inveterata is represented 
under the name of psoriasis inveterata. 



308 DISEASES FROM SPECIAL INTERNAL CAUSES. 

Lepra capitis. — Among the special regions which lepra is apt to 
attack, is the scalp, where it creates much irritation and considerable 
inconvenience, from the accumulation of scales which is apt to ensue. 
It commonly extends over the entire scalp, and to a short distance 
beyond the margin of the hair, advancing sometimes a little way on 
the forehead, but it rarely proceeds far, and never invades the whole 
extent of the forehead or the face. The skin is thickened and red, 
often torn by the nails, and the scales are thinner, and smaller, and 
more furfuraceous in their character than on other parts of the body. 
Lepra capitis is usually accompanied with patches of eruption on other 
parts, and notably on the elbows and knees. 

Lepra unguium. — When lepra is general in its eruption, the nails 
are very apt to become the seat of the disease, and undergo, in conse- 
quence, a morbid alteration. At first there is an appearance of a 
white deposit beneath them ; this deposit increases, and then they are 
separated from their matrix to a greater or less extent, and become 
thick and rugged. Their color also is changed ; they are yellowish 
and tawny, are apt to curve down over the ends of the fingers, or 
become brittle, and are not unfrequently ragged and broken. Some- 
times they are separated entirely from the matrix, and are cast off, to 
be replaced by others equally deformed and unsound. 

Diagnosis. — The pathognomonic characters of lepra are, the circular 
or circumscribed form of the patches, their elevated border and de- 
pressed centre, and their covering of well-defined scales. Their 
circularity of form is traceable by means of two or three broken arcs 
of circles, even when a number of disks have run together and formed 
one continuous patch of large size. 

Lichen circumscriptus, with its circular clusters of pimples fading 
towards the centre, may sometimes be mistaken for lepra in process of 
cure, but the identity of lichen is established by the presence of a few 
marginal papulae ; whereas in lepra, the inflamed surface, denuded of 
its scales, is perfectly smooth. 

Occasionally we meet with cases of chronic eczema and chronic 
lichen agrius, in circumscribed patches, in which it becomes very diffi- 
cult to determine whether or not they belong to the leprous eruption. 
These are, in fact, the cases to which the designation psoriasis properly 
belongs ; and careful examination generally determines their real 
nature, particularly if there be several such patches ; but sometimes 
the disease occurs in the form of a solitary patch. If there be no 
eruption on the elbows and knees, a prima facie case is made out 
against lepra ; and this is confirmed if there be any moisture or dis- 
charge about the eruption. The crust may resemble exactly that of 
irregular lepra, lepra diffusa. The difficulty is increased when the 
lepra presents itself in an irregular form, and when it has become the 
seat of eczematous congestion, and pours out the peculiar ichorous 
secretion of the latter disease. The case is then one of lepra compli- 
cated with eczema. 

Causes. — The cause of lepra is a special poison, the nature of which 
is obscure. I have stated my belief, and I see no reason to change 



LEPRA. 309 

that opinion, that the leprous poison is in its essence and origin 
syphilitic; that lepra is, in fact, a manifestation of the syphilitic 
poison, after transmission through at least one, and probably through 
several generations. In examples of constitutional syphilis, we not 
unfrequently meet with cases in which the resemblance between the 
eruption and that of lepra is so exact, that we feel bound to accept 
the term which has been handed down to us by our predecessors, 
namely, lepra syphilitica ; but lepra syphilitica differs from lepra 
vulgaris in this, that the former yields to the iodide of potassium and 
mercury ; but the latter is unaffected by those remedies. Again, I 
have published one example, and seen several, of a real lepra vulgaris 
in the children of a man who was under my care for the remote effects 
of syphilis, and who appeared, besides, to have had congenital syphilis. 
These facts are worthy of observation, and will, at least, afford a clue 
to the probable discovery of the mysterious cause of this most myste- 
rious and curious disease. 

Lepra is hereditary ; but, in some instances, it may be very difficult 
to determine its succession ; and sometimes it appears to be idiopathic. 
When undoubtedly hereditary, it presents the curious phenomenon of 
attacking only one out of a large family, and this without any expla- 
nation being admissible ; it is neither the strongest nor the weakest, 
the youngest or the eldest child that is afflicted. In few instances, 
comparatively, two children become the subjects of the disease where 
one of the parents suffers ; and in a case now before me, I have a 
mother and two children all under treatment at the same time for the 
same eruption. Lepra is not common in childhood ; but I have seen 
it between the fourth and fifth year ; it is more frequent after puberty, 
but may be developed at any period of life, being rather a disease of 
mid-age than of either extreme. 

The eruption often makes its appearance slowly and insidiously ; 
beginning by a single small spot, which gradually enlarges, then other 
spots appear ; very soon it is found on the elbows, and then a symme- 
trical arrangement is observable. Nerves from the same centre pro- 
ceeding to opposite halves of the body, develop the same morbid action 
in the parts to which they are distributed. Sometimes the eruption 
makes its first appearance after an exciting cause, such as mental agi- 
tation, bodily fatigue, exposure to wet or cold ; a severe illness, such 
as scarlet fever ; or excess of any kind. The exciting cause is simply 
the spark which fires the pile, already long prepared, and only await- 
ing the power which is to give it life and activity. 

Prognosis. — Lepra will often get well ; sometimes spontaneously, 
sometimes under the influence of medicine ; but lepra is more com- 
monly a life-long disease. Generally it is periodical, making its out- 
break in the autumn and winter, and getting well in the summer, when 
the skin is more active in its functions. At other times it is perma- 
nent, the only change being some variation under the influence of the 
seasons, or of the state of health of the person. I have a patient, a 
lady, the sister of an eminent physician, who comes to me once or 
twice a year for a little help for her troubles. She has had this vexa- 
tious complaint nearly fifty years. It began in her girlhood, and then 



310 DISEASES FROM SPECIAL INTERNAL CAUSES. 

she was consoled by being told that it would cease at womanhood; when 
womanhood came, and the disease was still there, she was to look for- 
ward to change of life as her period of cure ; now she requires no tell- 
ing that the shroud alone will cure her complaint. I could multiply 
examples, if such were necessary. Lepra is not a disease on which to 
build a medical reputation. 

Treatment. — Unlike diseases originating in general causes, lepra 
has no constitutional symptoms of its own, and its existence is per- 
fectly consistent with a complete state of health of the individual. 
But as the leprous patient may suffer from other diseases, these are 
apt to constitute so many complications of lepra, and may require to 
be relieved before the special treatment is commenced, or at any rate 
consentaneously with it. One of the most common complications is 
that form of mal-assimilation which gives rise to the gouty and 
rheumatic diathesis, and this is apt to occasion an inflamed and 
painful state of the eruption, and must be removed before the real 
treatment of lepra is begun. It would be a mistake, however, to fail 
to distinguish between that which is an accidental superaddition to 
lepra and the disease itself. Not unfrequently, in the presence of 
the gouty diathesis, the leprous eruption is attacked with a violent 
erythema, and not uncommonly it throws out the ichorous exudation 
of eczema. 

The treatment of lepra, therefore, presents two indications ; firstly, 
the removal of complications, together with the regulation of the as- 
similative organs ; secondly, the adoption of a course of specific reme- 
dies. 

The complications of lepra call for the same treatment that they 
would receive independently of their connection with lepra ; the treat- 
ment, in fact, which is laid down in the chapter on General Thera- 
peutics and in that on Eczema ; consisting of gentle aperients, salines, 
bitters with alkalies, bitters with the mineral acids, colchicum, &c. 
Occasionally the effects of this treatment are very remarkable. With 
the improvement in the general health, the lepra is always improved, 
and sometimes will get entirely well without specific remedies. The 
practitioner must not, however, in this event, rush to the conclusion 
that the remedies have cured the lepra, and will therefore cure it again. 
If he endeavor to put such an idea to the test of experiment, he will 
inevitably fail. The lepra, in his fortunate case, had reached its turn- 
ing-point ; it was no longer kept up by its own special cause, and was 
only prevented from healing spontaneously, as it not uncommonly 
does, by the constitutional disturbance then existing. The medical 
man allays the constitutional disturbance, and the lepra gets well, not 
by the virtues of his medicine, but spontaneously. It is the failure to 
see this fact in its true light that imports so many suggestions and 
remedies into the treatment of lepra, remedies which flourish for a 
week in the periodical in which they first appear, then probably lan- 
guish for a year in some annual abstract of delusive cures, and then 
are forgotten forever, and deservedly so ; not even leaving behind 
them the appreciation of that small, thin streak of truth upon which 
they were founded. A case of this kind happened to myself, which, 



LEPRA. 311 

as it is illustrative of the treatment of lepra, I will narrate. A gen- 
tleman, the surgeon of a London hospital — of that great metropolis 
that has hospitals for .every disease, real or presumed, but not a ward 
in all its magnificent hospitals for the instruction of students of medi- 
cine in cutaneous diseases — called me to see him during an attack of 
lepra, complicated with excessive debility and mal-assimilation. He 
had been humoring the fancy of a young medical friend, and had been 
bled somewhat largely, without any benefit, or other effect than that 
of contributing considerably to his weakness. He had suffered from 
lepra for many years ; but latterly, in consequence of the gouty com- 
plications to which I have referred, his attacks have been more violent 
than usual. Finding him so prostrate, that he had already taken 
aperient medicine, and that his urine was moderately free from lithic 
acid, while his tongue was large, pale, and indented, I prescribed the 
nitro-muriatic acid with gentian, and, as a local remedy to relieve the 
excessive irritation of surface, the oxide of zinc ointment. At my 
next visit, I found my friend better ; so much better, in fact, from his 
improved state of assimilation, that I did not think it necessary to see 
him again. At my first visit I impressed upon him the importance 
of having an ointment prepared of perfectly pure oxide of zinc ; and, 
to insure perfection in this respect, he had, he informed me, had some 
sent to him from the hospital. I was curious to see what went by the 
name of oxide of zinc ointment in a London hospital, and found stuff 
only fit for the stuffing-boxes of railway carriages. It is thus that 
ointments fall into disrepute, and an opportunity is given to some 
thoughtless scion of "young physic" to exclaim "Down with oint- 
ments !" " Down with all greasy applications !" But to return to my 
narrative. A few weeks afterwards I was asked by several medical 
friends to communicate to them a discovery I had made in the cure 
of lepra, a remedy that was attended with unbounded success; neither 
alkali nor arsenic. I was a little confounded at first by this sudden 
appeal, but, after a few questions, discovered the source of the rumor, 
and remembered my always good friend, the nitro-muriatic acid and 
gentian. 

As a specific in lepra there is but one reliable remedy, and that 
remedy is arsenic. In the chapter on General Therapeutics, I have 
already expatiated on the merits of arsenic, which, in judicious hands, 
is one of the best and safest remedies which we have in the pharmaco- 
poeia. Arsenic will cure lepra with certainty ; but neither arsenic nor 
any other knoAvn medicine will prevent it from returning again ; some- 
times, after a thorough dispersion by arsenic, the eruption never re- 
appears, but more frequently it recurs the following year, or after the 
lapse of several years. 

The pharmacopoeia is rich in arsenical preparations, but none ex- 
ceeds in practical utility the liquor potassse arsenitis, the solution of 
Fowler. The dose of this preparation is five minims, to be taken with 
meals three times a day. I frequently combine with it five minims 
of antimonial wine, and ten of tincture of ginger, making the dose of 
the mixture twenty drops. There is some advantage, in unsteady 
hands, in a mixture, of which a larger number than five drops is the 



312 DISEASES FROM SPECIAL INTERNAL CAUSES. 

dose; and probably if the dose were increased to thirty drops, a still 
greater accuracy would be secured. When the dose is limited to a 
few drops, I order these to be instilled on a fragment of bread, the 
piece of medicated bread to be eaten in the course of the meal. By 
this means I secure the perfect mixture of the arsenical solution with 
the ingesta, and from the comparative tastelessoess of the remedy, it 
is frequently preferred in this manner to any other ; and to prevent 
still further any inconvenience from flavor, I sometimes order the 
omission of the tincture of lavender from the liquor arsenicalis. If 
preferred, the dose may be taken in a little water, or in any fluid 
drunk during meals, hut I endeavor to impress on my patients the 
necessity of taking the medicine in* the middle or towards the end of 
the meal. To take it on an empty stomach, or before a meal, would 
be to invite its bad effects ; on a full stomach it rarely disagrees. 

In certain exceptional cases there is a great intolerance of arsenic, 
even in smaller doses than five minims, and when those cases come 
before us, we must adapt our remedy to the idiosyncrasy of our 
patient. If five minims be too much, we must reduce the dose to 
four, three, or two. Sometimes I find it convenient to exhibit the 
medicine only twice a day, instead of three times ; in a word, coax it 
in every possible way. And then, I never fail to give the patient 
instructions, that if the medicine disagree in any manner whatever, 
it is to be suspended for a day or more, and afterwards resumed as 
before. I add also to my instructions, that if the patient be out of 
health from any other cause than the medicine, such as common cold, 
&c, that then also the medicine should be omitted, lest the morbid 
symptoms in question should be aggravated by the arsenic, or lest 
indeed they may, unsuspectedly, have been promoted by it. 

In the chapter on General Therapeutics I have already enumerated 
the various preparations of arsenic known to us, and the symptoms 
which are occasioned by the use of the medicine in excess, or in too 
large doses. I may, however, in this place, distinguish two or three 
from the number, which may be employed in relief of Fowler's solu- 
tion, when this latter does not seem to agree with the stomach, or 
when for any reason a change of remedy is called for. Next to the 
arsenite of potash, I give a preference to the arseniate of soda, which 
may be administered in powder or pill. The dose of the arseniate of 
soda is the eighth of a grain three times a day, in combination with 
guaiacum, or with guaiacum and the oxysulphuret of antimony. 1 
After the arseniate of soda I prefer the solution of arsenic in hydro- 
chloric acid, the solutio solventis mineral is de Valangin, of which the 
doBe is from five to ten minims. This solution is convenient for 
giving with meals, as it harmonizes with the gastric juice, and has 
appeared to me, in some instances, to agree with the stomach better 
than the alkaline solutions. 

In very chronic cases of lepra, it may be found advantageous to 
combine mercury, and sometimes mercury and iodine with the 
arsenic ; and to meet a case of this kind, we have the iodide of mer- 

1 See " Selection of Formulae" in the last chapter. 



LEPRA. 313 

cury, and the triple solution of Donovan, the liquor hydrioclatis 
hydrargyri et arsenici. The dose of Donovan's solution is from ten 
to twenty minims three times a day with meals. The following is 
Donovan's formula for this preparation. 1 Triturate of finely levigated 
metallic arsenic, 6.08 grains; mercury, 15.38 grains; and of iodine, 
50 grains, with one drachm of alcohol, until the mass be dry, and 
changed in its color from a deep brown to a pale red. Next, triturate 
the mass for a few moments with eight ounces of distilled water, 
transfer the solution to a bottle, add to it half a drachm of hydriodic 
acid, and filter, making it up to eight ounces by means of distilled 
water, if there be any deficiency. The solution is of a golden yellow 
color, and each drachm contains ■ 

Water, 5jj. 

Protoxide of arsenic, . . . . . . . gr. £ 

Protoxide of mercury, . . . . . . . gr. £ 

Iodine, converted into hydriodic acid, . . . . gr. ^ 

Of the iodide of arsenic, 2 the dose is the tenth of a grain, and in no 
instance has it admitted of being carried beyond one-third of a grain. 
" Its obvious effects are, quickness and hardness of the pulse, with 
slight puffiness of the lower eyelids ; but, generally, before these 
symptoms of its influence display themselves, the disease has begun 
to yield." " The symptoms which indicate a necessity for reducing 
the dose are, heat of the mouth and fauces, and anxiety at the prse- 
cordia, with pain at the epigastrium, or griping. If, besides these, 
there is tension, with an uneasy sensation of stiffness around the eyes, 
and erythema of the face, thirst, a white tongue with the edges and 
tip of a florid red hue, and a quick pulse, the use of the medicine 
shoukl be suspended for some days. If nausea, cough, vertigo, or 
salivation, supervene, it should be left off altogether. The employ- 
ment of any arsenical medicine is inadmissible, if it cause an uneasy 
sensation of the chest from the first. Iodide of arsenic is incompatible 
with cinchona in any form." 3 

Liquor potassae and dilute nitric acid are among the remedies for 
lepra. The former may be taken in doses of from one to two drachms, 
two or three hours after a meal, three times a day, in any convenient 
vehicle, such as milk or beer, or in some medicinal infusion ; and is 
not incompatible with the arsenical treatment. The dilute nitric acid 
is incompatible with the arsenical treatment, and may be adopted in 
those cases wherein the stomach evinces a great repugnance to arsenic. 
The dose is, one or two drachms in barley-water, sweetened with 
sugar, to be taken an hour before meals, twice or three times a day. 
J have usually combined with this treatment a Plummer's pill at bed- 
time. 

Other remedies for lepra recommended from time to time by 

1 Dublin Journal of Medical Science, November, 1839, September, 1840. 

2 Dr. Anthony Todd Thomson's formula for the preparation of the iodide of arsenic 
is, hi lake " se*enty-fi v<- grains and a half of metallic arsenic, and six hundred and thirty- 
one grains and a balfof pun' dry iodine; rub them well together in a mortar, and sub- 
lime. The sail is thus obtained in the form of brick-red shining scales." 

8 Commentaries on Diseases of the Skin, &c 



314 DISEASES FROM SPECIAL INTERNAL CAUSES. 

different authors are, tar, tincture of cantharides, iodide of potassium, 
bichloride of mercury, and certain vegetable infusions or decoctions. 
In the presence of so excellent and certain a remedy as arsenic, it is 
difficult to find an opportunity for making trial of these medicines, 
and it is only where arsenic is found to disagree with the stomach, or 
as a change of remedy, that I should be induced to adopt them. I 
have prescribed the Barbadoes tar in capsules in some few cases, but 
have certainly not been impressed with its value'; and many patients 
have come to me uncured after a long use of tar, who have had the 
eruption speedily removed by* means of arsenic. The cantharides may 
be combined with Fowler's solution, where it may be thought desirable 
to employ it, as in those cases in which the kidneys appear to be tor- 
pid in their function ; but the tendency of this medicine to produce 
inflammation of the kidneys must at the same time be borne in mind. 
The iodide of potassium and bichloride of mercury, can only be re- 
garded and employed as supplementary remedies or adjuvantia.- 

The vegetable infusions and decoctions which have gained a repu- 
tation in lepra are simply to be regarded in the light of alterative 
diluents, diaphoretics, aperients, and diuretics; they are mild reme- 
dies, and require to be taken in considerable doses. As assistants to 
a more active treatment, and especially to the arsenical treatment, they 
may be found of value ; but alone, I should attach very little import- 
ance to their use. The chief remedies of this kind are, the decoction 
of dulcamara; decoction of the woods, namely, guaiacum, sassafras, 
and mezereum ; decoction of the arctium lappa or lesser burdock ; 
decoction of elm bark ; infusion of the urtica dioica, or common nettle ; 
and infusion of the galium aparine or goose-grass. The decoctum 
bardanse or decoction of the lesser burdock, is made by macerating an 
ounce of the root in twelve ounces of water, and then boiling~it with a 
slow heat down to eight ounces. This quantity to be the daily dose. 

Local treatment for the cure of lepra is useless ; but various indi- 
cations present themselves which render local treatment for the relief 
of irritation of the skin advantageous and necessary. An erythema- 
tous or eczematous state of the eruption, or a cracked and fissured 
state of the skin, will call for the use of the oxide of zinc ointment, 
with spirits of wine or glycerine. Where the scales cover a large 
extent of the surface of the body, a tepid soap bath or vapor bath is 
indicated, and is a source of much comfort. Various remedies are 
found to give relief by occasioning exfoliation of the scales, such as a 
lotion of bichloride of mercury; an ointment of carbonate of potash, 
of iodide <>f potassium, the white precipitate ointment, the concrete 
naphthaline ointment (5j ad §j), or tar ointment. For a dry and 
parched state of the eruption the best application is a lotion of equal 
parte of distilled glycerine and rose-water. 

For the accumulation of sordes and scales which takes place in lepra 
capitis, the besl application is the unguentum hydrargyri ammonio- 
chloridi ; and tor the dry, horny, rugged, and loosened nails. of lepra 
unguium, steeping them in glycerine. 

But I must repeat, the local treatment of lepra is not to be regarded 
as curative, it is simply palliative; the cure must come from within, 



lupus. 315 

from that improved and altered state of the blood which results from 
the proper administration of arsenic. 



LUPUS. 

The term lupus, or wolf, applied to a disease, is suggestive of 
destructiveness, and doubtless took its origin in a form of cutaneous 
affection which is remarkable for its destructive nature, namely, lupus 
exedens, called also, and for the same reason, lupus vorax. Destruction, 
then, we may take as the leading character of lupus. A further 
inquiry into the nature of lupus served, however, to show that this 
destructive disease was preceded by a circumscribed thickening and 
prominence of the skin, commonly termed a tubercle, hence, lupus is 
considered as a tuberculous affection of the skin, and is placed in the 
order tubercula of Willan. Now, the destructive action implied by 
the term lupus, was, in the first instance, intended to be restricted to 
that form of tubercle which commonly issues in destructive ulceration ; 
but as cutaneous diseases came to be more carefully observed, it was 
perceived that there existed a kind of tubercle which did not of a 
necessity ulcerate, which was chronic and lasting in its nature, and 
which, when it disappeared, under treatment or spontaneously, left 
behind it a deep pit or a strongly marked cicatrix ; this tubercle 
resembling the tubercle of the ulcerating lupus in many of its features, 
and being unlike all other forms of cutaneous disease, came therefore 
to be grouped under the head of lupus, being distinguished from the 
preceding by the specific appellation of lupus non exedens, or non- 
ulcerating lupus. Destruction by ulceration and destruction without 
ulceration are, therefore, the established characters of lupus. Now, 
experience has made us acquainted with a third form of disease, in 
which there is also destruction or atrophy of the superficial structure 
of the skin, but no ulceration and no tuberculous thickening; the 
only other outward sign of the disease besides the atrophy being ery- 
thema. This form of cutaneous disease has also been taken into the 
group of which lupus is the head, and has been distinguished by 
Cazenave under the name of lupus erythematosus. I myself have noted 
this latter affection, independently of the researches of Cazenave, and 
finding it arise in some instances from syphilis, have described it 
under the name of syphiloderma erythematosum hsereditarium. 1 In 
other cases the syphilitic origin of the disease is not so clear, and in a 
few examples I have been led to regard it as a remnant of elephanti- 
asis; hence, for the present at ]east, I prefer to leave the question of 
cause unsettled, and the affection itself in the present group. 

The varieties of lupus are, therefore, three in number, namely, lupus 
erythematosus, lupus non exedens, and lupus exedens. 

1 On Syphilis, constitutional and hereditary, and on Syphilitic Eruptions, 1852. 



316 DISEASES FROM SPECIAL INTERNAL CAUSES. 



LUPUS ERYTHEMATOSUS. 

Syn, Syphiloderma erythematosum hcereditarium faciei et capitis, 
Wilson. Erythema centrifugum, Biett. 

Lupus erythematosus occurs upon the face and head, principally 
on the nose and cheeks, in women, and sometimes in men. It makes 
its appearance in patches of irregular form and small size, generally 
single, but often two or three in number ; the patches are marked by 
erythema, the redness being greater near the circumference than 
within the area of the patch ; sometimes at the extreme edge the 
redness subsides by degrees into the tint of the surrounding skin ; at 
other times the patch is bounded by a slightly-raised, wheal-like 
border. In recent cases the wheal may have a delicate purple-red 
hue, the central area being whitish and opaque; in older cases the 
redness of the area is more confirmed. The area of the patch is 
always depressed, apparently from exhausted nutrition ; the skin 
looks dry and shrunken, as if its vitality were affected; the cuticle is 
yellow and horny; the sebiferous pores are distended with dry 
epithelial exuviae, the sebiparous glands appear to be in a state of 
atrophy ; and the term atroplried seems applicable to the whole of 
the affected skin ; it looks as if a fire had passed over it, parched 
and seared. 

The patches of skin affected with this disease are manifestly thinner 
than natural from interstitial absorption; if they occur among the 
hair, the hair follicles are obliterated, and the hair is permanently 
lost; if they occur upon the nose, the bones and cartilages become 
unnaturally prominent, and after a time the skin has the appearance 
of a cicatrix. When the disease gets well a permanent cicatrix 
is frequently left behind; at other times, when treatment has been 
adopted early, the skin may regain its normal thickness and ap- 
pearance. 

The disease often begins in a very insidious manner, as in a young 
lady now before me, aged seventeen ; a small pale spot, the size of a 
split pea, made its appearance on the centre of the cheek four months 
back ; it attracted her attention suddenly, it gave her no pain, caused 
no irritation whatever, but was obvious to the eye as a pale, flat, dry 
spot, perfectly smooth, and surrounded with a delicate purplish halo, 
abrupt towards the spot, fading into the surrounding skin, and 
perceptible rather by its contrast with the pale spot, than from any 
distinction between it and the general tint of the cheek. Now, it has 
increased to the size of a shilling, by the formation around it of other 
spots of a similar character to the first; and the collective patch 
presents a scalloped edge, marking the outer, boundary of six 
primary spots ; while at the upper part, a seventh spot has formed 
just outside the boundary of the existing patch. How slight a matter 
it looks ! and yet this apparently trifling thing will defy treatment, 
and possibly may increase so as to be unsightly ; or other patches of 
a similar kind may form. At present it hardly seems a thing for 
medical attention or treatment, and possibly would not attract the 



lupus. 317 

notice of any but the immediate members of the young lady's family, 
or a medical man who had directed his attention especially to such 
affections. For what is it ? a small pale spot with a scalloped edge, 
a narrow halo of a delicate purple, like a blush of breaking day ; and 
then the unchanged tint of the virgin cheek. How ridiculous it seems 
to look ominously at such a trifle, and to wish that it were something 
else of an infinitely worse appearance, in place of what experience 
tells us that it is. 

Lupus erythematosus of the face is frequently accompanied with a 
similar affection of the fingers, particularly in young women. The 
erythematous spots or blotches are usually of a circular figure, of a 
purplish red color, and slightly raised above the level of the surround- 
ing skin. They vary in size from two or three lines to an inch in 
diameter, and gradually become depressed in the centre ; -the cuticle 
in the centre assumes a whitish, opaque appearance ; gradually dries 
up into a thin, yellowish and horny layer, and desquamates from time 
to time. A common situation of these blotches is the joints, and they 
are generally mistaken for chilblains, until their obstinate persistence 
and their occurrence in the summer as well as the winter season ren- 
der this diagnosis doubtful. They are generally associated with cold- 
ness of the fingers and hands, which gives a color to the suspicion of 
their being chilblains. Like the similar affection of the skin of the 
face, the special character of the disease is atrophy ; and in a young- 
girl now under my treatment, the atrophy has extended to the whole 
of one finger, which is conical towards the end from loss of substance 
and contraction of the skin, and bloodless from the tight clasp of the 
skin upon the phalanges. 

LUPUS NON EXEDENS. 

Syn. Vitiligo. Leuce. 

Lupus non exedens 1 (Plate XIII.) makes its appearance in the form 
of one or more elevations of a circular or oval shape, slightly raised 
above the surface, and about two lines in diameter. The tubercles 
are of a dull red hue, or salmon-colored, and semi-transparent ; and 
not unfrequently they resemble a reddish transparent jelly effused upon - 
the skin, and streaked with the ramifications of a few small bloodves- 
sels. When pressed under the finger they are found to be soft, and 
when the finger is removed, they are blanched and flattened. The 
epidermis covering the tubercles is, at the beginning of the disease, 
smooth, but later, it cracks and peels off, and its white and broken 
margins are apparent around the circumference of the elevations. 
When more than one tubercle exists, they are usually found clustered 
together, and generally assume an annular disposition. The more 
common seat of this disease is the face, and more particularly the nose. 
I have also seen it on the lower eyelid, beneath the chin, on the lobe 
of the ear, and on the arm and leg. 

The tubercles of lupus give rise to little or no inconvenience 

1 Portraits of Diseases of the Skin, Plate XLV., AC. 



318 DISEASES FROM SPECIAL INTERNAL CAUSES. 

beyond their appearance, and may exist for months without undergo- 
ing any change. Occasionally they are scratched, and then a thin 
scale forms upon their summit. Then this scale is torn off, and 
another is produced; each successive scale being larger than the pre- 
ceding, and being the cause of a repetition of the act of scratching. 
After a variable period of time, more tubercles begin to be apparent 
around the borders of the original patch. Perhaps, this second crop 
assumes an annular form, and the primary tubercles have subsided 
and disappeared. The process by which subsidence and disappear- 
ance of the tubercles is effected seems to be one of absorption. There 
is no ulceration, and yet the tubercles leave cicatrized pits behind 
them. Sometimes the disease spreads superficially and more quickly 
over the skin, and then the surface which it has left is crossed by 
white scar-like ridges and bands. Every trace of the normal struc- 
ture of the skin has disappeared ; it has slightly sunk below the level 
of the surrounding integument, and the spaces between the white 
lines are pale, salmon-colored, and semi-transparent, the epidermis 
being smooth, thin, and glossy. Occasionally fresh tubercles spring 
up on this surface, and the disease is perpetuated. Sometimes I have 
seen the patches covered by thick crusts from the oozing of an icho- 
rous fluid following the abrasion of the skin. 

When the disease has subsided, the skin never resumes its original 
appearance, even where there are no cicatrices. The epidermis is 
very thin, the linear marking of the skin is lost, and it looks flabby 
and loose. Moreover, the natural sensibility of the skin is also de- 
stroyed, a change which may be perceived from the first appearance of 
the disease. 

When the tubercles attack the border of the ala of the nose their 
absorption causes a loss of substance of that organ, and gives to the 
external aperture a notched and irregular outline. When this change 
occurs towards the anterior extremity, the point of the nose becomes 
unnaturally acute. 

There are fragments of Bateman's description of vitiligo which are 
peculiarly applicable to lupus non exedens ; and I am disposed to 
believe that it was this disease which he had in view in writing his 
description. For example, referring to the tubercles, he remarks : 
" As they gradually subside to the level of the surface, they creep 
along in one direction, as for example, across the face, or along the 
limbs, checkering the whole superficies with a veal-skin appearance." 
The veal-skin appearance relates to the inside of the skin of the 
animal, an explanation without which the text is hardly intelligible. 
To the above comparison Batcman adds, " this white and glistening 
appearance, bearing some resemblance to the flesh of calves (vituli), 
seems to have given rise to the generic term." Again, he observes, 
in reference to the state of the skin, " a smooth shining surface, as if 
polished, being left, and a morbid whiteness remaining through life. 
The eruption never goes on to ulceration." Now, all this corresponds 
perfectly with the appearance of the area of a circular patch of lupus 
non exedens, or with the skin on which its devastations have been 
committed. 






lupus. 319 



LUPUS EXEDENS. 



Syn. Herpes exedens ; Herpes esthiomenes ; Noli me tang ere ; Dartre 
rougeante ; Hsthiomene serpigineuse, Alibert. 

Lupus exedens 1 commences, like the preceding, by a tubercle of a 
dull red color, but harder and denser in structure than those above 
described, and not transparent. The more frequent seat of the tuber- 
cle is the nose, either the ala or tip, and sometimes the border of the 
ala or the columna. After a variable period of time, during which 
the tubercle remains indolent, a thin brown and adherent scab forms 
upon its summit. This scab is usually scratched off, and another is 
produced in its place by the desiccation of an ichorous fluid which 
escapes from the abraded tubercle. On the removal of this latter scab, 
the skin beneath is found more or less deeply ulcerated, and the ulcer 
soon becomes concealed by another and a larger scab, resulting from 
the drying up of the ichorous and purulent secretion which is poured 
out on its surface. 

The ulcer, like the original tubercle, offers much difference in re- 
spect of rapidity of progress, being one while very slow, and another 
while very speedy, in its devastating course. When the latter ten- 
dency exists, the entire nose has been destroyed in less than a month; 
a character which is distinguished by the name of lupus vorax. The 
surface of the ulcer of lupus exedens is uneven, sometimes studded 
with unhealthy granulations, but more frequently covered with white 
patches of lymph. Its edges are thickened and red, and it frequently 
pours forth a considerable quantity of a fetid, ichorous, and semi-puru.- 
lent fluid. 

When the ulcer of lupus exedens heals, the cicatrix is remarkable 
for the white and corrugated bands, and the unhealthy-looking skin 
described in connection with the previous disease ; and the recurrence 
of the morbid action on these cicatrized spots is far from being un- 
common. 

The deformity which results from this disease is sometimes quite dis- 
tressing. I have now before me a lady about thirty years of age, in 
whom the eruption has crept from each check across the face, destroy- 
ing the nose completely, and producing so great an amount of contrac- 
tion, as to draw the lower eyelids down upon the cheeks ; and shorten 
the upper lip, so as to denude permanently the gums of the upper jaw. 
The lower segment of the eyeballs is completely exposed, and the con- 
junctiva congested from the irritation of the atmosphere ; the situation 
of the nostrils is marked by two round apertures of small size; the 
gums of the upper jaw are coated with sordes, and have retreated from 
the teeth, leaving them unnaturally elongated. On the cheeks and' ex- 
tending from the temples downwards to near the border of the lower 
jaw, the superficial ulceration continues, and over this has formed a 
very thick yellowish and blackish crust, which is broken into angular 
fragments of irregular form and size. 

Lupus exedens sometimes attacks the interior of the nose, and a 

1 Portraits of Diseases of the Skin, Plates XLVI., XLVIL, E, F. 



320 DISEASES FROM SPECIAL INTERNAL CAUSES. 

fetid discharge precedes the extension of the disease outwardly; it oc- 
casions much swelling. The disease also makes its appearance at the 
angle of the mouth, or upon the upper lip, and sometimes on the cheek ; 
and in these situations causes considerable tumefaction, with redness 
of the surrounding skin. 

Lupus exedens is occasionally met with as a superficial phagedenic 
ulceration of the skin. Such a case I have now under my treatment; 
it is remarkable for its perfectly circular figure. Now and then it ap- 
pears in the annular form, leaving a circular island of unaffected skin. 
When its tendency is to proceed inwards to the deeper tissues, the de- 
vastation which it occasions is often frightful; all the structures in its 
course, including even the bones, are destroyed ; the nares are laid 
open, the superior maxillary bones are necrosed, and the eyeballs, 
losing their support, sink into the chasm which the removal of the 
subjacent parts occasions. And all this without producing much pain, 
for the ulcers of lupus exedens, like their tubercles, are remarkable 
for deficiency of sensibility. 

Diagnosis. — Lupus is easily distinguished from other affections of 
the skin. Its dull-red indolent tubercles, in the first instance ; their 
incrustation or ulceration subsequently; and then the unhealthy-look- 
ing or deeply-pitted cicatrix, are pathognomonic characters. To these 
may be added, its seat; the nose, lips, eyelids, and neck, being its more 
common situations. Rayer observes, that " the solitary tubercles of 
lupus exedens of the cheeks have frequently been mistaken during 
their stationary period for small sanguineous tumors or nsevi." I 
have seen the tubercles of lupus non exedens present precisely this 
character. 

Causes. — Lupus seems to depend upon a scrofulous taint of consti- 
tution ; I believe hereditary syphilitic taint would be the more correct 
expression. It is more common in women than in men, and in the 
lower than in the middle and higher classes of society. 

Prognosis. — Uncertain and unsatisfactory ; the disease is always 
tedious, lasting for years or for life, and resisting often the best 
planned treatment. The indolent form is more favorable than the 
active kind. 

Treatment. — The treatment of lupus, whatever form it may assume, 
presents two indications ; firstly, to remove the local disease ; and 
secondly, by alterative tonic remedies, to improve the general state of 
health, and, if possible, act specifically upon the skin. 

For the lupus erythematosus I have found the liquor plumbi diacetatis, 
pencilled on the part night and morning, a good remedy, as also an 
iodide of lead ointment containing two parts of the salt to one of lard. 
Other local remedies applicable to this case are the oxide of zinc oint- 
ment, alone or in combination with glycerine, and the ointments of 
nitric oxide, and nitrate of mercury. As a constitutional remedy after 
regulating the system by general means, I give the preference to the 
liquor hydriodatis hydrargyri et arsenici, in doses of ten or fifteen 
drops with meals three times a day, and accompanied with the cod- 
liver oil, in doses varying from one drachm to an ounce, taken directly 



lupus. 321 

after meals, twice or three times a day. Cazenave recommends sudo- 
rifics internally, particularly guaiacum ; and, locally, tar ointment, or 
the iodide of mercury combined with olive-oil, in the proportion of 
half a drachm to the ounce ; to be pencilled on the eruption daily or 
every other day. 

For lupus non exedens the same constitutional treatment may be 
pursued as for the preceding; varying Donovan's solution with Fowler's 
or De Valangin's solution, and with the protioduret of mercury. 
Locally the tubercles may be destroyed by the chloride of zinc, nitric 
acid, or potassa fusa ; taking a few tubercles at a time, and prosecut- 
ing their destruction until all are removed. In cases where the tubercle 
is single or occupies a small extent of surface, removal by these means 
is generally successful. 

In lupus exedens the constitutional remedies and mode of treatment 
are the same as for lupus non, adding the bichloride of mercury, which 
.is sometimes of great service. The local treatment must consist of 
caustics, which destroy the surface of the ulcer, and excite a new and 
more healthy action. The caustics the best suited for this purpose 
are, the strong nitric acid, the potassa fusa, or the chloride of zinc. 
The nitric acid is to be made into a moist paste with the sulphur pre- 
cipitatum of the pharmacopoeia, and applied by means of a small 
wooden spatula. The potassa fusa may either be used to touch the 
surface of the ulcer, or made into a paste with quicklime ; and the 
chloride of zinc may be made into a paste, with the addition of two 
or three parts of flour to one of zinc. The Vienna paste, which is 
sometimes employed for this purpose, is composed of equal parts of 
potassa cum calce and quicklime, mixed to a proper consistence with 
spirits of wine. An arsenical paste, consisting of equal parts of arsenic 
and animal charcoal, has also been recommended ; and an arsenical 
powder, bearing the name of Dupuytren, composed of one part of 
arsenic mixed Avith two hundred parts of calomel. The chloride of 
gold and acid nitrate of mercury have also been mentioned as suitable 
caustic applications. The nitric acid paste may be left to dry on the 
part ; the Vienna paste takes from ten to twenty minutes to produce 
its proper degree of effect, and frequently requires to be guarded 
from contact with surrounding parts by means of a piece of plaster ; 
and the chloride of zinc paste may be allowed to remain undisturbed 
for from four to eight hours. The arsenical caustics are dangerous 
from liability to absorption of the mineral poison. 

After the caustic has been on for some hours, or when removed, the 
ulceration may be treated with water-dressing, either with oiled silk 
or with Alison's prepared lambskin, or with a dressing of the benzoated 
ointment of oxide of zinc, or liquor plumbi, or calamine ointment. 

M. Lemery, of St. Louis' Hospital, finding the ordinary remedies 
for lupus so little successful, had recourse to cod-liver oil, of which he 
speaks in the most encouraging terms. He begins with the dose of 
an ounce three times a day, increasing the quantity for fifteen days, 
by which time he reaches six ounces a dose. If the disease exhibit no 
indication of submission, he goes on till he arrives at two pints in the 
day. Should the stomach revolt, a glass or two of seltzer-water is 

21 



322 DISEASES FROM SPECIAL INTERNAL CAUSES. 

given ; and if any symptoms of derangement of the alimentary canal 
or fever supervene, the oil is suspended, but commenced again at the 
minimum dose as soon as the symptoms disappear. 1 

M. Devergie, M. Lemery's colleague in St. Louis, states that M. 
Lemery has over-estimated the benefits of cod-liver oil, but that in the 
serpiginous form of the disease, before ulceration has commenced, he 
has undoubtedly found it of service. He mentions the iodide of iron 
with favor; and, as ? an application to the ulceration, the oil of juniper 
applied every fourth day. The tubercles he treats with caustic. 2 

SCROFULODERMA. 

Cutaneous scrofula presents itself to our notice in two forms, namely, 
that of tubercles, and that of ulcers. 

Scrofulous tubercles are of small size, indolent, of a purplish or 
livid color ; they soften internally, open and give exit to an imperfect 
pus, often remain open or fistulous for a considerable time ; and when 
at last they finally disappear, frequently leave behind them a hard knot 
in the skin. They are most commonly met with on the neck and face, 
and in the neighborhood of -ulcers or the remains of ulcers resulting 
from inflammation of the lymphatic glands. These tubercles increase 
so slowly in size, that they are often several months before they attain 
maturity, and, if of any bulk, are apt to open at several points, the 
result of softening of separate parts of their structure ; and when these 
openings take place successively, the tubercles continue in a fistulous 
state for many months longer. When the softened contents of the 
tubercle have been partially discharged, that which remains forms a 
crust over the aperture, and when the crust is from time to time dis- 
turbed or displaced, a fresh exit of ill-formed pus or ichorous fluid 
takes place, and the opening continues for an indefinite time, without 
showing any disposition to heal. When the healing is at last accom- 
plished, an ugly scar or cicatrix is often left behind. 

Scrofulous ulcers may be the result of cutaneous or subcu- 
taneous abscesses, and may vary considerably in their depth ; like the 
tubercles already described, they are extremely indolent, their edges 
are purplish and livid ; they throw up no granulations, or, if any 
appear, they are of a flabby and unhealthy character ; they emit an 
ichorous, almost colorless discharge ; are often fistulous, and either 
resist healing altogether, or heal slowly and imperfectly, leaving 
behind them a livid or purplish scar of irregular form and puckered 
and rugged surface. Scrofulous ulcers are most commonly met with 
in the neck, near enlarged lymphatic glands, and in the neighborhood 
of joints. 

In scrofulous subjects, particularly in young persons, it is not un- 
common to find an inflammation of the matrix of the nail, scrofu- 
loderma ungueale. The disease begins by inflammation and swelling 
of the skin immediately around the edges of the nail, the extremity 
of the finger swells considerably, and becomes vividly red ; and the 

1 Revue Medieo-Chirurgicale, vol. iv. 2 Bulletin Therapeutique, 1848. 



SCROFULODERMA. 323 

scrofulous hypertrophy frequently extends to the whole of the tissues 
of the part, even to the bone, producing a clubbed finger. The nail, 
after a time, becomes separated, and leaves an angry-looking raw 
surface, upon which a rugged, ill-formed, and imperfect nail is from 
time to time produced. The denuded derma, covered with fungous 
granulations, secretes more or less of an unhealthy pus, and the disease 
is kept up for a considerable length of time, often for many months. 

With these manifestations of scrofula in the skin, it is common to 
meet with other indications of the existence of constitutional scrofula 
in other parts of the system, such as enlarged glands, enlargement of 
joints, swelling of the upper lip, accompanied with a chapped and 
fissured state of the skin, and indolent abscesses. 

Scrofulus tubercles commonly occur singly, sometimes a group of 
three or four appear in close proximity, and sometimes the morbid 
action spreads in an annular form upon the surrounding integument, 
leaving an area of thin, shining skin, of a livid or purplish color. I 
have met with rings of this kind, chiefly on the back of the hands 
and feet, where they are peculiarly intractable. The tubercles are 
disposed in an irregular manner around the circumference of the ring, 
and often only along a segment of the circle ; they become more or 
less blended together, and they present in a mass the characters which 
have been described as belonging to individual tubercles. They are 
covered more or less completely with yellowish or dark-colored 
adherent crusts ; and when these crusts are removed, the surface looks 
wormeaten and papillated, and the small ulcerated hollows are filled 
with an unhealthy-looking pus. 

The treatment of scrofulous tubercles and scrofulous ulcers calls 
for judicious constitutional management, as well as local remedies. 
The four great hygienic principles, air, exercise, temperature, and diet, 
all require regulation. The diet of scrofulous persons should be 
generous, embracing as much meat as possible, and a fair proportion 
of stimulus ; while appetite and digestion should be promoted by air, 
exercise, and a genial atmosphere. The medicinal remedies are, the 
whole family of tonics, including iron, iodine, and cod-liver oil ; and 
the local remedies, mild stimulants. The tubercles may be destroyed 
by nitric acid or chloride of zinc, and afterwards dressed with some 
mild digestive ointment, such as the unguentum elemi or unguentum 
balsami peruviani ; or with a soothing and healing ointment, such as 
that of the benzoated oxide of zinc. Scrofulous ulcers also require 
a digestive and moderately stimulant treatment, and are generally 
greatly benefited by pressure, as by a dressing of adhesive straps, 
and, where the part will admit it, by the application of a bandage. 
For the scrofuloderma ungueale, nothing answers so well as the ben- 
zoated ointment of oxide of zinc, cither alone or in combination with 
Peruvian balsam. 

At the recommendation of Mr. Peter Price, I have employed the 
iodide of ammonium with advantage, using it at the same time 
internal! v and externally. For internal exhibition the dose is two or 
three grains, twice or three times a day, in any suitable vehicle, such 
as the compound fluid extract of sarsaparilla, or syrup of orange-peel. 



324 DISEASES FROM SPECIAL INTERNAL CAUSES. 

And for external use a convenient formula is one drachm of the salt 
dissolved in an ounce of glycerine, and applied with a camel's hair 
brush to the enlarged glands night and morning. 

KELIS. 

Kelis, like lepra and lupus, probably originates in a specific 
poison existing in the blood, the nature of the poison being obscure 
and unknown. The disease makes its appearance in the form of an 
elevated thickening of the skin or tubercle, increases in dimensions, 
and when two or three tubercles occur, they are apt to become blended 
and form an elevated and flattened mass, often of considerable size. 
Sometimes the tubercle or tumor is isolated and single ; more fre- 
quently there are several, and sometimes they are sprinkled nume- 
rously over the skin. When their development is complete, they 
remain stationary for years, and sometimes subside and disappear ; they 
may attack either the deep or the superficial stratum of the derma, 
and appear to select for their pathological seat the fibrous element of 
the skin. When the deep portion of the corium is the seat of the hy- 
pertrophous growth, the surface of the skin is little affected ; but when 
the disease invades the superficial stratum of the derma, the papillary 
layer of the skin is absorbed, the blood of the capillaries is driven 
back upon the larger branches of arteries and veins, and the white 
fibrous structure of the corium is seen through the soft, velvety, and 
semi-transparent layer which constitutes the surface. The tubercles 
of kelis have no tendency to ulceration, and rarely terminate by 
absorption. 

Kelis admits of a division into two kinds, according to its seat of 
origin, in the sound skin, or in a cicatrix left by some previous injury 
to the skin, such as a burn or ulcer. In the former situation it is 
termed the true kelis, kelis vera ; in the latter, kelis spuria. 

KELIS VERA. 

Syn. Kelois. Chelois. Cancrois. Keloides. Kelis vera; genuina ; ovalis ; 
radiciformis ; cylindracea ; clavata. Dartre de la graisse. Der Knol- 
lenkrebs, Germ. 

The disease of the skin termed kelis, was first particularly described 
by Alibert, who distinguished it by the name of " cancroide ;" assigning 
as his reason for selecting that term the judicious practice of early 
observers, of designating diseases by the names of the things which 
they most nearly resembled. The word "cancroide" is therefore 
intended to draw the attention t^o a supposed resemblance in form 
between this disease and a crab, and is synonymous with "cheloide," 
derived from /yr,, forceps cancrorum, the term used by Rayer and 
Gibert, by reason, remarks the latter, of the likeness which the pro- 
longations of the tumor bear to the feet of the crab. Another name 
given to this affection, and one which I regard as most correct, and 
have- therefore adopted, is kelis, derived from ztjA;?, macula, vel pro- 
brnrn ; this term having reference to the singularly cicatrix-like appear- 
ance which the disease so frequently presents. 



KELIS. 325 

Besides the preceding, Alibert had another reason for employing 
the term " cancroide " — namely, that of associating this disease with 
cancer. The cancroids, he observes, maintain a relation both with 
tetters and cancers ;• like the latter, they often give rise to acute, pun- 
gent, and lancinating pains; and he asks, "Will they form an inter- 
mediate genus?" This is a more important question than that of the 
etymology of the disease. 

It is quite true that in many of their features the keloids have a 
remarkable resemblance to cancer, for example, in their hardness, 
whiteness, the meandering of small veins on their surface, the total 
disorganization of the skin, their extension into the deeper parts of 
the skin by root-like prolongations, and, above all, in the acute, burn- 
ing, smarting, and lancinating pain with which they are frequently 
attended. On the other hand, it must be admitted, that they rarely, 
if ever, pass spontaneously into a state of ulceration ; they have none 
of the large and tortuous veins which surround a cancerous tumor, 
the adjacent skin is wholly unaffected, the lymphatic glands are not 
implicated, the tumors are extremely slow in their progress, often 
stationary for years, and sometimes they disappear entirely. . 

Cazenave and Schedel remark, that the kelis should be " carefully 
distinguished from cancerous affections, with which, in truth, it has 
very little analogy." Rayer says, that "keloid formations do not seem 
to have any deleterious influence on the general health." Dr. Warren 
calls it a "troublesome and dangerous disease." Troublesome it is 
certainly, but I do not consider it dangerous ; and I am of opinion 
that the case upon which Dr. Warren founds his inference of the dan- 
ger of kelis was not an instance of this disease, but one of cancer. He 
states that it affected the ala of the nose ; that, after several extirpations, 
"a considerable tUmor appeared on the face, and another under the 
jaw," while, a fortnight after, "a tumor is seen extending from the 
right eye and side of the nose to the cheek, where there is a frightful 
enlargement, including all the textures of the face and gums." 

According to the admission of all writers on the subject, the disease 
is rare ; so much so, that the total number of cases which I have suc- 
ceeded in finding recorded, amounts only to twenty-four ; whereof 
twelve are reported by Alibert, five by Rayer, three by Biett, two by 
Gibert, one by Dr. Warren, 1 and one by Dr. Peace. To this number 
I may add seven that have occurred in my own practice. 2 

Of the twelve cases reported by Alibert, eight occurred in women. 
From this circumstance he was led to deduce the inference, that the 
disease was more common in females than in males. Five out of my 
seven cases, on the contrary, were males ; while four out of the five 
mentioned by Rayer were also males. Of the entire twenty-seven, 
the sex is unmentioned in three ; and of the remainder, fourteen were 
females and ten males. 

The cause of kelis must evidently be sought for among those con- 

1 The second case reported l>y Dr. Warren appears to me to be an instance of carcino- 
matous disease rathei than of Kelis. 

2 Subsequent experience enables me to estimate the proportion of cases of kelis to other 
cutaneous a'lfeotions at about one in two hundred. 



326 DISEASES FROM SPECIAL INTERNAL CAUSES. 

ditions of the constitution, -whatever they may be, which give rise to 
lupus and cancer. In five of my seven cases there existed no known 
cause, and the same may be said of the majority of the examples 
reported by other authors. In four only of the twenty-seven cases is 
anything like a remote cause established, and that of so trivial a 
nature as to be obviously inadequate to the production of so grave a 
disease. In one of Rayer's cases, the tumor sprang from the cicatrix 
of a burn received in childhood; in another, it arose from the cica- 
trices of small-pox ; and in a third, from the cicatrix of a small 
punctured wound ; while, in one of Alibert's cases, the remote cause 
was a slight scratch. Of the two instances in which I was enabled to 
trace the growth to a cause, I found one to result from the application 
of irritating substances to the skin ; and the other to originate on the 
seat of application of a blister. From this circumstance I felt inclined 
to classify these two cases with others which are seen more frequently, 
and which are termed "false kelis." These latter may always be 
traced to some local alteration of the skin, such as a cicatrix. 

With the exception of one of Alibert's cases, I find no reference 
made to. any hereditary disposition to carcinomatous disease ; in the 
instance in question, a sister of the patient died of cancer uteri. The 
mother of one of my patients died, he informs me, of a similar disease, 
but I can trace nothing of the kind in the families of the other 
patients. 

The similarity of position of the morbid growth in the greater 
number of the recorded examples of this disease is very remarkable. 
In three of my cases the tumor occupied the centre of the sternum ; 
while, of twenty-two cases (of the before-mentioned twenty-four) in 
which the seat of the disease is stated, thirteen were situated on the 
same spot. 

A matter of the first importance in a practical point of view, is the 
degree of annoyance which these tumors are calculated to give to our 
patients. Alibert observes that they are the torment of existence, 
that they are usually attended with increased heat, that they are often 
accompanied with itching and pricking to an extent that is insupport- 
able, that the pain is acute, pungent, and lancinating, and like the 
piercing of the skin with burning needles. That often the pain 
extends to surrounding parts, and occasionally there is as it were 
a dragging from within. On the other hand, they are sometimes 
indolent, and merely give rise to stiffness of the skin. The cases seen 
by Raver appear to have been of the milder kind referred to by 
Alibert ; he remarks, that, at their commencementj they are mere 
points, and these points are affected with "pruritus of a pretty severe 
description." When they increase to the size of a "small hazel-nut 
or the barrel of a quill," they are generally indolent, " unaffected with 
morbid heat or pain," and very seldom, indeed, the seat of "anything 
like painful shooting sensations." Further, he says, that the incon- 
venience they occasion is, in general, so trifling, that he has known 
patients "refuse to submit to the curative means proposed for their 
relief." Cazenave and Schedel state, that the little tumors arise 
and grow without pain ; in other respects, these authors follow the 



kelis. 327 

description of symptoms given by Alibert. Dr. Warren mentions a 
case which was accompanied with a '-stinging, burning pain." In 
Dr. Peace's case the tumor originated without pain, but, after eighteen 
months' growth, was so painful as to prevent the patient from lying 
on the affected side. 

In a good example of kelis illustrated in my "Portraits," 1 the 
patient was a robust man, forty-eight years of age. The disease first 
attracted his attention about seven years before his application to me. 
He then perceived upon the middle of the breast four slightly-raised 
tubercles, which 'coalesced, and gradually increased in size, until they 
formed a broad-spreading, irregularly-shaped excrescence. In figure 
this excrescence bore some resemblance to a bird, the head of the bird 
pointing toAvards the right breast, the wings spreading out above and 
below, and the body and broad tail crossing the sternum to the left 
breast. The length of the kelis, from the head-like process to the 
opposite extremity, was three inches and three-quarters, while, across 
the wings, at its broadest part, it measured three inches. Its eleva- 
tion from the surface of the skin varied between two and three lines, 
the most elevated part being at its border. 

On a first inspection, the morbid excrescence had the appearance 
of the cicatrix of a burn, and, upon closer examination, the only 
character at variance with that idea was its elevation from the sur- 
rounding skin, particularly at its borders. Its color was pink, lighter 
in the centre than at the circumference, and it was marked on the 
surface by a coarse network of prominent white lines or ridges. The 
general direction of these white lines corresponded with that of the 
long diameter of the kelis, but, upon the four processes of the 
excrescence they had a transverse or semicircular direction. From 
these processes a number of red and white lines were given off, which 
resembled roots shooting into the substance of the unaffected skin. 

It was also evident, from an examination of the kelis, that its 
growth proceeded by an extension of the margins of the four processes 
only, while the intermediate portions of its border, namely, those 
forming the angles between the processes, were drawn onwards over 
the sound skin, without participating in the deeper growth. The 
borders in these situations were rounded and free, about two lines in 
thickness, and a probe might be passed beneath them to a distance of 
half an inch, and, in one or two places, to a greater depth. Indeed, 
these hollow ways were a source of some inconvenience to the patient, 
by serving to collect dirt and flue from his dress, and he was obliged, 
from time to time, to have recourse to means for clearing them out. 

Besides the pink hue of the excrescence, its cicatrix-like lines and 
ridges, the depressions between the latter, and its elevated borders, the 
snrface of the kelis presented a smooth polish, like that of the new 
skin of the cicatrix of a burn, and a sort of semi-transparency. There 
were also visible, here and there, particularly about its circumference, 
several small meandering bloodvessels, apparently veins, collecting 
the returning blood from minute tributaries. 

1 Portraits of Diseases of tin- Skin, Plate XLIV., R. 



328 DISEASES FROM SPECIAL INTERNAL CAUSES. 

To the touch, the kelis gave the idea of a hard, resisting structure 
like fibro-cartilage, invested by a soft, velvety-seeming skin. The 
central portion was harder and more dense than the circumference, 
and the white lines had all the rigidity of bands of fibrous tissue. 

The patient's application to me had reference to the propriety of 
removing the excrescence, in consequence of the pain and annoyance 
to which it had given rise during the last three years, and more 
particularly as the pain was evidently on the increase. At times he 
Buffered much from excessive itching ; at other times the pain was 
smarting, burning, and shooting ; and occasionally he experienced a dart- 
ing sensation, which he compared to an electric shock. The pain did 
not endure long, but it recurred frequently, and was excited by any 
movement which produced pressure on the growth, such as bringing 
his shoulders together, or lying on his side in bed. He was not aware 
of any increase of pain depending on change of season or weather, 
and the excrescence underwent no alteration of color or bulk from 
mental or bodily excitement, exercise, or elevation of temperature. 

Besides the kelis on the breast the patient has a second on the outer 
side of the left leg, over the head and upper part of the shaft of the 
fibula. This excrescence is of the cylindrical kind (keloide cylindra- 
cee Alibert), and, like the preceding, is accompanied by its satellite, a 
small round tubercle, situated near its lower end, on the calf of the 
leg. The cylindrical kelis measured three inches in length, and was 
broader at the extremities than in the middle ; measuring at its 
narrowest point one-quarter of an inch ; at its upper end three-eighths 
of an inch ; and at the lower end five-eighths of an inch. Its eleva- 
tion was about one line. 1 

The patient is not aware of any cause for this disease, either local 
or general ; no scratch, no abrasion or undue friction of the skin, as a 
starting-point. He was in good health at its first appearance, and has 
remained so since. None of his family have suffered from anything 
similar. His mother died of cancer of the womb at the age of seventy- 
one, having been first attacked by that disease Avithin twelve months 
of her death. 

A London physician, forty-one years of age, had two of these 
tumors of the cylindrical kind ; one being situated on the right 
shoulder, over the spine of the scapula, the other on the buttock of 
the same side. 

They first attracted his attention about five or six years ago (1845), 

1 Since the completion of the above details 1 hnve again seen the patient. The kelis 
on the breasl is more painful than it has ever been, and is slowly on the increase. The 
pain is confined to the edges of the excrescence, and is greatest where the growth is most 
active, the central part being comparatively insensible. On requiring him to take off his 
clothes, 1 observed four tubercles of keloid formation on the left arm; they were situated 
on the cicatrices of as many boils, which had resulted from an accident he had met with 
six years before. He had been thrown out of a chaise, and falling on his left side, had 
sprained his wrist. The arm became swollen and inflamed, and when the inflammation 
Subsided, the boils made their appearance. He had not mentioned these enlargements to 
me, because he considered them as merely the remains of the boils. They had always 
man milled the same size, were never painful, but were occasionally affected with pruri- 
tus. He informs me that he had never suffered pain from the kelis on the leg, but has 
sometimes been troubled with pruritus. 



KELIS. 329 

■when the tumor on the shoulder was not larger than a horse-hean. 
At present it measures an inch in length, by one-third of an inch in 
greatest breadth, and has an elevation of about one line. This tumor 
presents obvious indications of having originally consisted of three 
hemispherical tubercles, subsequently united by a connecting ridge. 
The tubercles having been of different dimensions, the kelis is larger 
at one end than at the other, and the connecting ridge is nodulated 
near the larger end, from the presence of the third and smallest 
tubercle. 

The kelis on the buttock consists, in like manner, of two tubercles 
of unequal size joined together by a narrow ridge. The length of this 
formation is one inch and a half, and its greatest breadth somewhat 
less than three-quarters of an inch. 

The color of the growths is a dull pinkish red ; they are smooth 
and even on the surface, are covered by a very thin epidermis, and 
have none of the white lines of the previous case. They are soft 
superficially, but hard, dense, and resisting, like fibrous tissue, in 
their deeper structure, and they are strictly limited to the skin. 

Their most characteristic symptom is an occasional stinging, hot 
pain, compared by the sufferer to piercing the skin with a fine needle 
made red hot, and a tingling, itching sensation, after being touched or 
rubbed, or under an increased degree of cutaneous circulation, such 
as occurs in hot weather. A vehement desire to scratch is awakened 
by tbe itching, but, on the whole, they give rise to little pain or 
annoyance. In the summer they are more troublesome than in the 
winter season. 

During the last two summers, and particularly the last, the kelis 
on the buttock was excessively tender, so tender, in fact, as to cause 
pain on the slightest friction, as in that occasioned by the clothes 
in walking. 

A gentleman, forty-four years of age, of ordinary stature, stout, and 
of full habit, by profession an actuary in a Metropolitan Assurance 
Society, had his attention drawn about eight years since, in conse- 
quence of suffering a violent itching of the skin, to a small tumor 
situated on the middle of the breast. The little tumor was oval-shaped, 
smooth, of a reddish color, and about the size of a split horse-bean. 
From this time the itching in the tumor and immediately surrounding 
skin frequently recurred, more especially after any kind of mental or 
physical excitement, after taking wine, after walking, or upon getting 
warm. Occasionally there were, superadded to the pruritus, sensa- 
tions of smarting, stinging, burning, and prickling, particularly on 
the occurrence of atmospheric changes. In speaking of these sensa- 
tions, he compares them to the sudden piercing of the skin with a 
number of needles. 

The tumor continued to enlarge gradually for the first two years; 
it then remained stationary, only changing with his state of health, 
for the next five years ; and, during the last twelve or fifteen months, 
has been slowly diminishing in size. At present it is very slightly 
convex, or nearly flat on the surface, and lies across the middle of 
the sternum, resembling in its general form a sheaf of wheat, being 



330 DISEASES FROM SPECIAL INTERNAL CAUSES. 

narrow at the middle, and broad at either end. Its greatest length 
is one inch and three-quarters ; its breadth, at the middle, one-third 
of an inch ; and at the expanded extremities, nearly one inch. It is 
thickest at the narrow mid-portion, where it has an elevation of one 
line, and from this point gradually subsides to the level of the 
surrounding skin. 

Its color is pink, with a whitish line running longitudinally through 
its middle, and dividing, at its expanded portion, into four or five 
indistinct radiating streaks. It is, and always has been, perfectly 
smooth and polished ; and, upon close inspection, a great number of 
minute venules may be seen meandering from its central part to the 
circumference. In consequence of the tension of the skin, the promi- 
nences of the pores of the follicles are obliterated, and it might easily 
be mistaken for the projecting cicatrix of a deep burn. When 
examined with the finger, the skin is found to possess a velvety 
softness, beneath which may be felt a hard cord running through the 
middle of the tumor, and dividing, in the expanded portion on each 
side, into four or five smaller cords, which extend like roots into, and 
appear to be lost in, the deeper structure of the corium. This hard 
cord and its terminal branches correspond with the whitish longi- 
tudinal line and its radiated streaks above described. 

The principal change which the kelis has undergone in the progress 
of growth, is a greater amount of general elevation of the whole 
tumor, and a special prominence of the central cord and its radii. 
The patient informs me that, at the acme of its growth, it had an 
elevation of three-quarters of an inch at its central part. He also 
states, that it underwent frequent changes of dimensions having 
reference to his state of health, being one while swollen, and another 
while contracted in size. It has never been wrinkled, nor has there 
been any cuticular exfoliation from the surface. 

In his youth, this gentleman suffered very much from headaches, 
which were followed by partial loss of hearing, and were probably 
occasioned by some morbid change in the bones at the base of the 
cranium. The pains have long since ceased, but the deafness remains. 
There is one other circumstance in his medical history which deserves 
to be mentioned. At the age of nineteen, he was troubled by the 
growth of an indurated tumor from the conjunctiva of the upper 
eyelid. The tumor enlarged, during twelve months, to the size of a 
cherry, which it resembled in appearance, and projecting downwards 
over the eyeball, completely obstructed his vision. Some medical 
friends, among whom was the late Mr. Walker of St. George's 
Hospital, agreed, in consultation, that the tumor should be removed, 
but, as the patient was a little out of health, and the growth of the 
disease slow, it was arranged that the operation should be deferred 
for three weeks, during which time the patient should take some 
gentle aperient medicine daily. At the end of the three weeks, 
however, the tumor was so much reduced in size, that ihe operation 
was postponed, and in two months it had disappeared entirely. 

I am induced to dwell on the speedy and complete absorption of 
the conjunctival tumor, from the parallel which it meets with in the 



KELIS. 331 

history of "the kelis. When the latter was at the height of its growth, 
the patient, at the request of a relative, consulted the late Mr. King, 
of Maddox Street, with a view to an operation, not, the patient dis- 
tinctly avers, from the inconvenience or annoyance of the disease, 
but merely from the apprehension of its growing larger, and some 
day becoming troublesome. Mr. King, finding the disease limited to 
the skin, suggested his leaving it to itself, remarking, that if it ever 
extended to the deeper tissues, it would then be time to effect its 
removal. No remedies of any kind have been used, and yet, as we 
have seen, after attaining a certain amount of growth, a spontaneous 
absorption has set in, which has resulted in the very considerable 
reduction of its size, and the total cessation of the uneasy symptoms 
which once existed. 

I may add, that my observation of the above disease originated in 
an accidental exploration of the chest with the stethoscope, in order 
to determine the state of the heart and its valves. 

Since the date of my special inquiry into the nature of kelis, 
namely, in 1851, I have seen many cases of kelis vera. One, occu- 
pying a large extent of surface on the left breast, occurred in an 
American gentleman. When the tumor first appeared, it had been 
removed by operation, and the result of the operation was a great 
increase of the disease. In another case, the patient is a lady, whose 
chest is covered with a crop of small tubercles, twenty or thirty in 
number, and varying in diameter from three to six lines. Another 
case is also that of a lady, who has a large, flat, dumb-bell tumor on 
the right shoulder, and a smaller one of the same nature over the left 
scapula. In the two latter cases the seat of the hypertrophous growth 
is the deep stratum of the derma. 

KELIS SPURIA. 

Kelis spuria is that tubercular prominence of the tissues of the 
skin which not unfrequently takes place in the cicatrix of a burn, of 
a scrofulous ulcer, of a surgical operation, or in that caused by the 
destruction of the cutaneous tissues in confluent small-pox. This 
kind of kelis appears to be composed of white fibrous tissue, and 
presents the character of an elevated and elongated ridge to which 
several bands and cords from the surrounding altered structure of 
the cicatrix converge. The false kelis appears to be the joint result 
of hypertrophy, condensation, and concentration of the white fibrous 
tissue of the skin, and by a special power of contraction, would seem 
to draw the rest of the cicatrix to itself, and produce a puckering of 
the adjacent surface. 

Treatment. — Judging from the preceding sketch of the symptoms 
of kelis, it will be concluded that the disease may occasionally become 
excessively annoying, from the degree of pain which it occasions, 
from its inconvenient situation in respect of dress or the position of 
the patient, or from the apprehension of ultimate results, to which it 
may give rise, in the mind of the patient, or, indeed of the practi- 
tioner. On the other hand, it is consoling to reflect that the tumor 



332 DISEASES FROM SPECIAL INTERNAL CAUSES. 

has scarcely ever been known to take on an ulcerative or destructive 
action, or to attain a dangerous bulk. Nevertheless, the patient may 
be so anxious for relief as to desire an operation, and then, the ques- 
tion arises as to the propriety of using the knife. Alibert and Rayer 
have both mentioned the possibility of the spontaneous disappearance 
of the disease, and one of my cases is an apt illustration of the fact. 
On the other hand, although excision may have been successful in 
one or two instances, yet, in the majority, the operation has been 
followed by a reappearance of the disease in the cicatrix, and conse- 
quently, m a position more unfavorable than that of the original 
affection. The secondary kelis has also been generally found to be 
more active in growth and more painful than its predecessor. In Dr. 
Warren's case the diseased structure was twice excised; and after 
the second operation he thus describes its appearance: The tumor 
was " about two inches long, and half an inch wide, of a slightly red 
color, raised from the surrounding skin like the scar of a burn, and a 
small red projection extending from its edge. A burning and shoot- 
ing was felt in the parts. At each of the points where the needle 
was passed through, there was a little rising similar to the first, and 
about the size of a pea, and quite red, so that, instead of one tumor, 
there were seven." In a case reported by Alibert, in which the kelis 
was removed, the wound was many months before it healed, and the 
disease returned with more intensity than before. 

The conclusion which naturally results from these observations is 
unfavorable to operative procedure, and in no case, as it appears to 
me, is an operation warrantable until every chance of relief by other 
means has failed. 

The treatment heretofore pursued has been chiefly local. Alibert 
remarks, in his octavo work, that he had been successful in curing 
two cases by cautery with nitric acid ; but, as, in a reprint of the 
same work, he omits this observation altogether, and speaks unfavor- 
ably of all kinds of treatment, I am inclined to think that the disease 
must have reappeared in those cases. Rayer inclines to the use of 
pressure, and, in an instance that came under his care, considers that 
some benefit resulted from this plan ; he also alludes to the failure of 
excision and cauterization. Biett thinks that frictions with hydrio- 
date of potash might be found advantageous : and Cazenave and 
Schedel are of opinion that the sulphur vapor douche has been bene- 
ficial in softening the tumors. 

For my own part, I prefer, after regulating the general functions of 
the system, the maintenance of a steady course of Donovan's solution, 
in doses of ten drops, three times a day ; or of the protioduret of 
mercury in combination with guaiacum and the oxysulphuret of 
antimony. The false kelis I have succeeded in removing by means 
of three-grain doses of the iodide of potassium three times a day, and 
a Plummer's pill at bedtime. 

Locally, the best applications arc, collodion, to produce mechanical 
pressure ; liquor plumbi diacetatis, as a sedative to be pencilled on 
the tumor ; the preparations of iodine, either the tincture, or the 
solution of the iodide of ammonium, as recommended for scrofulo- 



ELEPHANTIASIS. 333 

derma ; or an ointment of iodide of lead, in the proportion of two 
parts of lead to one of lard. The latter remedy relieves immediately 
the prickling and uneasy sensation that often accompanies kelis. 
Great comfort is frequently given by the galbanum and opium plaster 
spread on wash-leather ; or, if there be no irritation, soap plaster or 
diachylon on' wash-leather. 

ELEPHANTIASIS. 

Elephantiasis, the Leprosy of the Jews; the Leprosy of the 
Middle Ages ; the Leprosy of the Crusades ; the Leprosy of the 
Arabians ; and the Elephantiasis of the Greeks, Elephantiasis GraB- 
corum, is a disease of much interest, on account of its early existence 
and almost universal diffusion throughout the world, its intense 
severity, its spontaneous disappearance in countries where it had 
raged with great violence, and its continuance in others, with all its 
original and historical characters, up to the present time. We read 
of it in the Bible, as prevailing amongst the Jews during their 
residence in Egypt, and after their exodus into Judea ; and in the 
New Testament, as still afflicting them in the time of Christ. We 
trace it from Syria into Persia and Hindostan, Turkey, Greece, Italy, 
France, Spain, Britain, Germany, Russia, Scandinavia and America. 
Besides being so widely distributed, we find it rising and declining at 
different periods in different parts of the world, moving gradually 
from the East to the West, and from the South towards the North. 
Probably limited in the early periods of the world to Egypt 1 and 
Syria, and confined to that region at the commencement of the 
Christian era, the disease spread with rapidity through Greece and 
the South of Europe during the period ranging from the second to 
the seventh century, reaching its culminating point during the Cru- 
sades of the eleventh and twelfth centuries, and began to decline from 
the fifteenth to the seventeenth century. 

The earliest records of the leprosy in Great Britain are those of 
the Welsh king, Hoel Dha, in the year 950 ; and from that date until 
the beginning of the sixteenth century, the disease was common in 
England. At the latter period, namely, during the reign of Edward 
the Sixth, 1547 to 1553, it is reported by a commission for suppressing 
colleges, hospitals, &c, that most of the Lazar-houses in England 
were empty. In Scotland, leprosy appeared one or two centuries later, 
the earliest Lazar-houses dating back to about 1150, and the disease 
was still traceable during the seventeenth century ; in 1604, a leprous 
woman was ordered into the Lazar-house at Aberdeen, and a notice 
of the same date exists of the presence of patients in the hospital at 
Kingscase, near Ayr. Symptoms of decline of the disorder in Scot- 
laud are perceived in an order for dismantling the Lazar-house at 
Grecnside, Edinburgh, in 1652 ; but in the islands to the north of 

1 " Hifjh up the Nile, 'mid Egypt's central plains, 
Springs the dread Leprosy, and there alone." 

Lunetius De Ntiturft Rerum. Poetical version by 
John Mason Good, M.D. 



334 DISEASES FROM SPECIAL INTERNAL CAUSES. 

Scotland, the Orkneys, Shetland, and Faroe Islands, the disease was 
in full activity. Towards the middle of the eighteenth century, 
namely, in 1742, leprosy was supposed to have disappeared in the 
Shetland Islands, and a public thanksgiving was ordered to commemo- 
rate that event; but instances still presented themselves occasionally, 
as is shown in the account of the parish of Northina\\n, given by 
Mr. Jack, in 1798, and by the more homely instance of a man named 
John Berns, who, in 1798, was a patient in the Edinburgh Infirmary. 
This man was a native of Shetland, and a direct descendant from 
leprous ancestors. 1 

But while leprosy has thus seemingly been disappearing altogether 
from Great Britain, there are yet many spots amongst its old haunts 
where it still lingers ; as on the shores of the Mediterranean, both in 
France and Italy, as well as in Greece ; on the shores of the Black 
Sea. where it goes by the name of Mai de la Crirnee; on the shores of 
the Caspian Sea; in the islands of the Indian Ocean; in the West 
Indies ; in Madeira ; and notably in Iceland and on the coast of 
Norway. In Norway, the prevalence of leprosy has been so great 
and so fatal that a royal commission was appointed a few years back, 
to examine into the nature of the disease, and determine the course to 
be taken to limit its progress, and if possible, effect its cure. The 
report of this commission, by Dr. Danielssen and Dr. Boeck, was 
printed by the Norwegian Government in 1848; it is accompanied by 
a fasciculus of excellent plates, and is by far the best treatise on 
elephantiasis in existence. 2 

The name elepltanta or elephantiasis was given to this disease by the 
early Greek and Roman writers ; the term occurs under a poetic 
synonym in Lucretius, who says, " There is a disease called elej)has, 
which has its rise on the river Nile, in the middle of Egypt, and in 
no other country." 3 Aretaeus, who knew the disease well, and has left 
a good description of it, explains that it received its name from the 
resemblance of the diseased skin to that of the elephant, and particu- 
larly from its vastness and terrible nature. A similar idea gave origin 
to the terms morbus herculeus and morbus heracleus. Other names, 
such as Leontia, Leontiasis ; Satyria, used by Aristotle ; Satyriasis, 
Satyriasmos, had reference to the deformity of countenance produced 
by the thickening, rugosity, and discoloration of the skin of the face. 
The heavy, lion-like brow is very remarkable; and it seems more 
than probable that the original idea of Satyrs was suggested to the 
poets by the appearance and habits of the lepers, who, driven from 
society, lived in holes and caves in the woods, and subsisted by 
robbery and violence. The latter circumstance caused them to be 

1 Dr Simpson, of Edinburgh, has given an excellent and interesting account of the 
Leprosy in Great Britain, in a series of papers entitled " Antiquarian Notices of Leprosy 
and Leper Hospitals in Scotland and England,'' published in the " Edinburgh Medical and 
Surgical Journal," for October, 1841 ; and January and April, 1842. 

2 Traite de la Spedalskhed, ou Klephantiasis des Grecs ; par I). C. Danielssen, Me*decin 
en chefde9 Hopitaux de Spedalsques a Bergen; et Wilhelrn Boeck, Professeur de le Fac- 
ulte de Medecine u Christiana. Paris, 1848. 

3 De Natura, Rerum; translated by the Rev. John Selby Watson. Lucretius was born 
ninety-five years before Christ. 



ELEPHANTIASIS. 335 

distinguished in Italy by the names of malandriosi, or brigands ; 
riobman, or robbers ; and latrones and ladres, thieves ; thus ignoring 
the cause of their original expulsion from society, and confusing their 
actions with their sufferings. The Arabians styled the disease judam, 
juzam, alzuzam, dsjuddam,madsjuddam,jeddem, muzdjeddem, didyam, 
damadyand, dschiddam, sghiddam, judas, &c, probably on account of 
its early victims being the Jews. It has, besides, received local names 
in different countries ; on the shores of the Black Sea, it is called 
mcdadie de la Orimee, lepre de la Chersonese, lepra Taurica ; and in 
Persia, from its supposed origin in the Crimea, krimskaia. In India 
it is named fisanikhun, or khora, kushta (leprosy), mahakushta (great 
leprosy) soubharry, and jugaru ; in Africa, kohan, koban, and kokobe; 
in Greece, it is popularly known as the lova ; in Italy, it is called il 
male di san Lazaro, male di commachio, il male di fegato, lebbra ; in 
Spain, mal rojo ; and in France, ladrerie. The term mal rojo, used 
in Spain, calls the attention to the dark red or reddish brown hue of the 
diseased skin ; while in other countries it has been named mal noir, 
also from the dusky hue of the skin, and to distinguish it from the 
common, white leprosy, lepra. In Britain, the old Saxon terms seo 
mycle adl (the myckle ail, or great disease), hreof and licprower have 
been given to it, together with the modern appellation, the black leprosy; 
the first of these terms applies to the severity of the complaint ; the 
terms hreof and licprower signify knotty or tubercular, the latter found 
in the Northumberland dialect, evidently corresponds with the Nor- 
wegian word LIKPEA. 1 Dr. Simpson remarks that the old Scottish 
name for leprosy was Liper. The victims of the disease were called 
Lipper Folke, and a celebrated spa and place of resort for them, two 
miles from Edinburgh, was thence named Liberton, a corruption of 
Liper Town. The Scandinavian designation of the disease is spedal- 
skhed, and in Sweden, spetalskhan ; in Norway it is also called arvesy- 
gen, or hereditary disease, and likpra, that is knotty or tubercular ; in 
Denmark, besides spedalskhed, likwaer thing and likwoerthingsof ; and in 
Iceland, holdsveiki, leinafalls-syki, likthra and malaottosott. In some 
parts of South America it has received as an appellation, the term boasi. 
We must now turn for an instant to an episode in the history of 
the nomenclature of elephantiasis, which has been and is a source of 
much confusion. Elephantiasis was, as we have seen, the leprosy of 
the Jews, of the middle ages, of the crusades ; it was a disease which, 
rising on the banks of the Nile, spread throughout the whole of 
Europe, from the South towards the North, from the East to the 
West. It was a disease of great fatality and frightful severity, 
and its characters are well known amongst all nations. It was not 
confined to a single member or to a part of the body, but occupied, 
more or less the whole; and was attended with symptoms which 
proved the entire mass of the blood to be impregnated with the 
poison that gave it origin. Under these circumstances, it is some- 
what remarkable that a comparatively local affection, the Barbadoes 
leg, Bucnomia tropica (Mason Good), should have been mistaken for 

1 Drs. Danielssen and Boeck, loc. cit. 



336 DISEASES FROM SPECIAL INTERNAL CAUSES. 

elephantiasis, and handed down to us in the records of medicine a8 
the Elephantiasis Arabum. The Barbadoes leg, which has no affinity 
whatever with elephantiasis, was from the enormous size to which the 
limb affected with this disease grows, the discoloration and rough- 
ness of the skin, compared by the Arabian physicians to the foot of 
the elephant, and called da ool feel or dal fil, the elephant disease. 
The Greeks and Romans, having no knowledge of this disease, in 
translating the works of the Arabian authors, mistook it for the dis- 
ease familiar to themselves, and called it Elephantiasis ; so that, to the 
present day. we are obliged to warn the student of the error, and dis- 
tinguish impressively Elephantiasis G-roecorum, the true and only 
elephantiasis, from Elephantiasis Arabum, the Barbadoes leg. But 
this was not the only mistake : the Arabian physicians, who knew 
elephantiasis well, called it, as has been already mentioned, judam, 
juzam, &c; these terms the Greeks translated by the word lepra. So 
that the judam or elephantiasis had now to be distinguished as the 
lepra Arabum, in contradistinction to the lepra already known to the 
Greeks, the lepra Grcecorum, corresponding with the common lepra of 
the present day. These three diseases, then, perfectly distinct from 
each other, are almost inextricably confounded, namely, elephantiasis, 
bucnomia, and lepra; elephantiasis having for its synonyms, lepra 
Arabum, lepra Judaeorum, and lepra medii gevi ; bucnomia, or Bar- 
badoes leg, having for its synonym, elephantiasis Arabum ; and lepra, 
for its synonym, lepra Graecorum. The only way at present left to set 
right the difficulty, is to abandon both the Arabs and the Greeks, and 
retain only the more simple designations of the three diseases, elephan- 
tiasis, bucnomia, and lepra. 

Elephantiasis is a blood disease, probably originating in an animal 
poison, and manifesting its existence either by the deposition of a 
peculiar albuminous substance in the skin, mucous membrane, and 
other surface tissues of the body, or by affecting chiefly the nervous 
centres and the nerves. This double mode of manifestation of the dis- 
ease has caused its division into two kinds, tubercular and anaesthetic ; 
the former being that which is characterized by deposition in the sur- 
face membranes of the body, particularly the skin ; the latter, that 
which is occasioned by deposition in and around the nervous centres 
and nerves. Both forms are chronic in their course, commencing 
insidiously, progressing slowly, and lasting for years ; sometimes 
terminating in spontaneous cure, and sometimes in death. 

ELEPHANTIASIS TUBERCULOSA. 

Syn. Elephantiasis orientalis ; legitima ; leonina. Lepra elephantia ; 
leontina ; medii eevi ; tuberculosa ; nodosa. 

Elephantiasis tuberculosa may be known by the development on 
the Bkin of erythematous patches, patches of discoloration or maculae, 
and tubercles ; similar patches and tubercles being also met with on 
the mucous membrane of the mouth, fauces, n'ares, and eyes. The 
erythematous patches are of a dull red or purplish hue, more or less 
vivid, and vary in size from half an inch to two inches or more in 



ELEPHANTIASIS. 337 

diameter. They are commonly rounded in form, most deeply colored 
in the centre, and fade towards the circumference ; after a time, the 
redness of the centre subsides or gives place to a brownish stain, while 
the circumference spreads for a short distance, and forms a ring with 
a well-defined border ; later still the redness disappears entirely, and 
leaves behind it a brownish or bronzed stain [morphoea nigra), which 
is more or less permanent. Sometimes the central portion of the patch 
becomes bleached, and perfectly white and smooth [morphoea alba, 
leucos, leuce), and is either bordered by an erythematous rim or by 
the abrupt line of the sound skin somewhat deeper tinted than the 
rest. To the touch, the centre of the erythematous patches is harder 
than the surrounding skin ; the epidermis frequently desquamates 
over this part ; the tissues of the skin become more and more con- 
densed, sometimes remaining perfectly flat, and sometimes attaining, 
by continued thickening, the elevation of a tubercle. The tubercle, 
when newly formed, presents the dull red and purplish hue of the 
erythematous patch, but sooner or later assumes either the bronzed 
tint of the discolored skin, or is whitish in hue, from the whitish albu- 
minous substance deposited in its tissue. After a duration of several 
weeks or months, the tubercles subside, leaving behind them a mark 
resembling a cicatrix thinner than the surrounding skin, and either 
bronzed or white. The tubercles vary in size from that of a pea to 
that of a pigeon's egg ; sometimes they remain unchanged for years ; 
at other times they become inflamed, soften, and ulcerate, and give 
forth a whitish, granular, albuminous substance, and a yellowish-white 
ichorous secretion. Sometimes this secretion concretes over the sur- 
face of the ulcer, and forms a dark crust of considerable thickness, like 
that of rupia ; at other times, the ulcer remains open, becomes deep 
and excavated, is bordered by irregular, callous, and prominent edges, 
the circumference being uneven, hard, livid, and often painful, and 
secretes an abundant, yellowish-white fluid. After a time, during 
which the morbid disposition in the skin is eliminated, the ulcer closes 
and heals, leaving behind it a hard, white, irregular, and prominent 
cicatrix. As one ulcer heals others form, and go through the same 
process, and the disease is thereby prolonged for an indefinite period, 
in some instances terminating in spontaneous cure, but more frequently 
resulting fatally from constitutional irritation, kept up by a similar 
morbid state of the mucous and serous membranes. 

The mucous membrane evinces a similar succession of morbid phe- 
nomena to those already described as occurring in the skin; the con- 
junctiva is congested, thickened by infiltration, so as to form an ele- 
vated ring around the cornea, the cornea becomes opaque, deposition 
of the peculiar whitish matter of the disease ensues, forming a tubercle, 
(lie tubercle softens and ulcerates, and the eye is destroyed. The Schnei- 
derian membrane undergoes corresponding changes; the nasal passages 
are obstructed by the thickening and swelling of the lining membrane, 
and broken up by the softening and ulceration which follow ; the latter 
causes perforation of the septum, denudation of the bones, and the nose 
becomes flattened and distorted. The mucous membrane of the mouth, 
fauces, pharynx, and larynx, exhibits the same train of appearances, con- 

22 



338 DISEASES FROM SPECIAL INTERNAL CAUSES. 

gested patches, tubercles, and ulcerations. The voice is hoarse from 
thickening of the lining membrane of the larynx, tubercles form upon 
the glottis and epiglottis, and both are destroyed when softening, fol- 
lowed by ulceration, ensues. Post-mortem observation shows that the 
same morbid action extends throughout the mucous membrane of the 
trachea and bronchial tubes ; deposits and tubercles are found also in 
the pleurae and lymphatic glands of the lungs, but the tissue of the lungs 
escapes altogether. So also the morbid action may be traced through- 
out the alimentary canal to the mesenteric glands, and to the peritoneum 
and its subserous tissue. In the closed membranes of the body, how- 
ever, although deposition is considerable, and the formation of tuber- 
cles abundant, the latter proceeding to softening, there is no ulcera- 
tion. In the liver tubercles are formed, both on the surface and in the 
substance of the organ, and, when softened, are converted into a thick, 
yellowish matter. The spleen, kidneys, bladder, uterus, Fallopian tubes, 
and ovaries, also suffer in a similar way, but the pancreas escapes. The 
kidneys, from their depurating function, are always found diseased, 
even when the other internal organs are healthy. The lymphatic glands 
are enlarged by the same morbid deposition, when the parts of the 
body which they represent are in a state of disease. The invasion of 
the internal organs by the morbid process only occurs in an advanced 
stage of the affection of the skin ; and, when the abdominal organs have 
become involved, and are seriously disorganized, the semilunar ganglia 
are sometimes found softened and destroyed. The coats of the blood- 
vessels also suffer from deposition and thickening, as do the sheaths of 
the nerves, the latter more particularly in the anaesthetic form of the 
disease; but the muscular system, the deep cellular tissue, and the 
bones, are never attacked. 

Although the erythematous patches and maculce are the result of a 
constitutional febrile action, an eruptive fever, in fact, which may be 
so slight and ephemeral as altogether to escape observation, but which 
must necessarily determine to the entire surface of the skin, the parts 
of the body on which the disease first appears are those most exposed 
to the action of the atmosphere, namely, the face and the hands. The 
erythema is sometimes so slight and transient, that a discolored spot 
is the first trace of the disease to be perceived. These erythematous 
patches, and brownish or bronzed stains, first appear in the superciliary 
region ; they are succeeded by thickening of the skin, and then by 
the development of the skin in the form of tubercles, which form a 
hea\y mass along the eyebrows. A similar change pervades the 
whole face, the skin is bronzed, uneven, the pores more evident than 
natural, the skin between the pores turgid, like the rind of an orange, 
the natural folds of the skin are thickened, and the wrinkles more 
deeply furrowed. These changes are most remarkable where the skin 
is naturally thin and white, as upon the eyelids ; but it is nowhere 
so striking as along the brow, whereon it hangs like a lowering frown, 
and gives a lion-like sternness to the countenance — elephantiasis leonina ; 
leontiasis. Concurrently with the development of tubercles along the 
Buperciliary ridge, the hair of the eyebrows falls, and this forms one 
of the strong characteristics of elephantiasis, elephantiasis alopecia. 



ELEPHANTIASIS. 339 

The ears also, early in the affection, become the seat of thickening and 
tubercles, the helix sometimes presenting the appearance of a circular 
tubercular border ; and sometimes the lobule of the ear is elongated 
considerably. Let us, then, array before the mind's eye the features 
here described : the discolored and wrinkled forehead, the prominent, 
tuberculated, bald eyebrows, the erythematous and bronzed skin, the 
congested eyes, thickened eyelids and lips, and the enlarged, red, and 
lengthened ears, and we shall at once perceive those characters of 
countenance which the poet and the painter bestow on the satyr, and 
which have gained for this disease, amongst others of its synonyms, 
the names satyria, satyriasis, satyriasmos. The suspicion of inordinate 
venery does not seem established, and admits of explanation in other 
ways ; neither does the statement that persons afflicted with this 
disease are incapable of procreation. The hands afford another charac- 
teristic of the disease ; erythematous and brown patches are early 
developed on the backs of these organs and on the fingers. The latter 
are remarkable for their thin and taper form, as well as for their brown 
color, and for a bluish whiteness of the nails. The skin of the fingers 
is thinner and paler than natural, and there exists in them a greater 
or less degree of numbness and insensibility. 

Defective sensation, indicative of the participation of the nerves in 
the general disease, is therefore a feature of the tubercular form of 
elephantiasis, although considerably less marked than in the anaesthetic 
form. The development of the erythematous patches is attended with 
some little increase of sensation, but the brownish and bronzed stains 
(morphoea nigra) are benumbed, and, more decidedly, the white spots 
(morphoea alba), particularly when attended with induration of the skin, 
from deposition of the white albuminous substance of elephantiasis. 

The constitutional symptoms which precede and accompany the de- 
velopment of elephantiasis tuberculosa are such as might be inferred 
to belong to a disease dependent upon the generation and accumula- 
tion of a poison in the blood ; and the degree of violence of the 
symptoms may be supposed to have reference to the quantity of poison 
present, and the susceptibility of the individual.. Sometimes the local 
disease, always slow and gradual in its progress, is unaccompanied by 
any perceptible constitutional disturbance ; at other times, a pretty 
smart fever indicates the accumulation of the poison to the point of 
excess, and Nature's effort to expel it from the body ; the direction 
taken by the poison being, as in the case of most other animal 
poisons, the skin and mucous membrane. The precursory symptoms 
are, a general feeling of languor, lassitude, dulness, weight of limbs, 
indisposition for motion, depression of spirits, and somnolency, with 
nausea and occasional chills. After a longer or shorter period, the 
eruption appears, and the_ constitutional symptoms gradually subside. 
The erythema and maculae, in their turn, have a duration of several 
weeks, and sometimes months, when they also decline, leaving behind 
them little trace <>!' their existence. At an uncertain period, the 
constitutional symptoms return, and are followed by another burst of 
erythematous blotches, with a like amount of relief to the general 
system. These periodical attacks are repeated from time to time, the 



340 DISEASES FROM SPECIAL INTERNAL CAUSES. 

constitutional symptoms being sometimes milder and sometimes more 
severe, but the effects on the skin now become permanent ; the 
bronzed blotches no longer disappear, and the erythematous conges- 
tions are perpetuated in the form of tubercles, which, at a more 
advanced period of the disease, pass into the ulcerative stage. The 
eruptive, depositive, and ulcerative stages always relieve the constitu- 
tional symptoms, and when the discharge from the ulcers is most 
profuse, the general health is at its best ; any check to the discharge, 
from the healing of ulcers or any other cause, being accompanied by 
fever, and by a more rapid progress in the deposition of the morbid 
product of the disease in other parts of the skin or mucous mem- 
brane. When the disease attacks the mucous membrane or internal 
organs, other symptoms occur which indicate its special seat : thus, 
the affection of the conjunctiva and eyeballs causes loss of vision ; 
that of the mucous membrane of the nose, loss of smell ; that of the 
mouth and tongue, loss of taste ; and that of the larynx and air-tubes, 
hoarseness, loss of voice, dyspnoea, and bronchitis. When the 
lymphatic glands are affected, there is more or less oedema of the 
cellular tissue; when the kidneys are attacked, albuminous urine; 
and when the mesenteric glands and mucous membrane of the intes- 
tinal canal are implicated, marasmus and colliquative diarrhoea. 
Under these secondary affections the patient gradually sinks, and dies 
from exhaustion. 

Drs. Danielssen and Boeck remark, that elephantiasis tuberculosa 
sometimes, but very rarely, occurs in an acute form, in which case the 
eruptive fever is violent, accompanied with delirium, and lasts from 
twelve to fifteen days ; the eruption rapidly passes into the tubercular 
stage, the patches of erythematous skin becoming oedematous ; the 
tubercles soften, and in a few weeks the disease accomplishes the 
progress of years. The disease may now subside into the chronic 
form, or, failing that, the patient may be carried off by pneumonia, 
pleuritis, or meningitis, in the course of a few days. 

The average duration of elephantiasis tuberculosa, according to the 
same authors, is nine years and a half. Thus, of eighty-eight patients 
who died of this complaint in the Hospital of St. George, at Bergen, 
during the years 1840-47, one, between forty and fifty years of age, 
lived two years : while another, between twenty and thirty, dragged 
on a miserable existence for twenty-two years ; and fifty- four out of 
the eighty-eight, nearly two-thirds, died between the periods of six 
and eleven years, both inclusive. 

KLEPHANTIASIS AN^ESTHETICA. 

Syn. Elephantiasis alopecia ; lepra alopecia medii cevi ; lepra articu- 
lationum; lepra mortificans ; lepra Arabum anai*t]tetos ; lepra 
/'///(■(jmatica ; lepra rheumatic a ; leuce vulgaris ; vitiligo alba, ■ 
Celsus. Spiloplaxia indica, Alibert. 

Elephantiasis anaesthetica is characterized by symptoms which 
indicate the primary seat of the disease to be the nervous system ; and 
the morbid appearances in the skin are such as naturally result from 
defective innervation. The progress of the disease is slow and 



ELEPHANTIASIS. 341 

insidious, and the constitutional phenomena, although essentially the 
same as in the tubercular form, are milder and less distinct. There 
is languor, lassitude, dulness, depression of spirits, and disposition fpr 
solitude ; the skin is pale and shrunken, the countenance anxious, 
and the muscles soft and reduced in size; in a word, insensibility and 
atrophy are the distinguishing features of the anaesthetic form of 
elephantiasis. 

The effort of evolution by the skin, instead of producing erythe- 
matous patches followed by brownish or bronzed maculae, results in 
the formation of white patches (morphoea alba) and bullae. The 
bullae are solitary or few in number, and of large size, varying from 
one to three inches in diameter ; they are developed suddenly and 
without pain, and burst in the course of a few hours, discharging a 
semi-transparent, viscous, greenish-yellow, and sometimes milky 
fluid. The bullae leave behind them an inflamed and ulcerated 
surface, sometimes painful ; the secretion from the denuded surface 
forms a thin, brownish crust, which, after a time, falls off, and is 
followed by a second, which, in its turn, is succeeded by others. 
When the ulcer heals, its place is occupied by a cicatrix, of which 
the skin is white, smooth, depressed, less sensitive than the surround- 
ing skin, and destitute of hair ; resembling, in fact, the white patches 
of morphoea alba already described. If hair return upon these 
patches, it is always white and fine, and the restored skin is deprived 
of its glandular structure. For several years fresh and fresh crops of 
bullae continue to be formed and succeeded by white patches, without 
any further change. 

As the disease advances, larger surfaces of the skin become the seat 
of an erythematous blush, the redness being very slight, and having 
a lilac or purplish tint; these surfaces also evince an increase of 
sensation, and are accompanied by a prickling pain, sometimes of 
considerable severity, like that occasioned by pressure on a nerve. 
The erythema is only of short duration, but the prickling, sensitive 
condition of the skin may last for months or even years ; and when 
it at last subsides, the skin is left pale and insensible, deprived of all 
secretion, from atrophy of the glandular organs, and like parch- 
ment, sordid and discolored. When the face is the seat of these 
changes, the countenance is emaciated and cadaverous, the features 
lose all expression, the skin hangs in folds, or is drawn tightly over 
the bones; the lower eyelid droops, producing ectropium. and leaving 
the conjunctiva dull and dry ; the eyelashes fall out ; the tears flow 
over the cheeks; the nose is pinched; the lower lip hangs down, 
leaving the teeth and gums exposed; the latter recede from the 
teeth ; and the saliva trickles from the mouth. In the limbs, the 
paralysis of the nerves gives rise to thinness and insensibility of the 
skin and atrophy of the muscles. The fingers are remarkable for 
their slender and taper form ; and the wasting of the interossei 
muscles of the metacarpal spaces,. particularly of the first, is patho- 
gnomonic. As the muscles waste, their balance of power is lost ; 
the extensors draw the first phalanges backward on the dorsum of 
the hand, while the second and third phalanges are bent inwards by 



842 DISEASES FROM SPECIAL INTERNAL CAUSES. 

the flexors ; the fingers first, and then the entire limb is distorted, 
and the joints are rendered conspicuous by their prominence — ele- 
phantiasis nodosa ; joint evil. Similar changes take place in the feet. 

Later in the progress of the disease, a purplish, painful spot becomes 
developed in the foot or hand, generally first in the sole of the foot ; 
it opens, discharges a viscous, ichorous fluid ; the loose skin covering 
it sloughs, and an ulcer is produced. The ulcer is atonic and insen- 
sible, has thick, callous edges, deeply excavated, extending into the 
substance of the muscles, sometimes denuding the bones, and pours 
forth a copious ichorous secretion. The ulcer continues for months, 
or even years; and if it heal, as is sometimes the case, another is 
quickly formed to take its place. Indeed, the comfort and well-being 
of the patient are dependent on the quantity and continuance of this 
secretion ; for, if the quantity diminish, febrile symptoms immediately 
ensue, and if it cease, the constitutional symptoms are so severe as 
greatly to increase the degree of paralysis, and often to threaten life. 

In a more advanced stage of the disease, when insensibility has 
increased to so great a degree, that a lighted taper may be held to the 
skin without giving pain, a new and pathognomonic symptom arises. - 
One of the fingers or toes is seized with a severe lancinating pain, 
which seems to have its seat in the bone ; the part swells, becomes 
purple or livid, points, and gives exit to a viscous, ichorous .fluid. 
The pain ceases by degrees ; the bone is exposed, loosens, and is 
expelled through the ulcerous opening. The ulcer then closes and 
heals, and the finger or toe is left shortened and distorted. After a 
brief interval, a similar process is repeated in another finger or toe, 
and in this way the greater number of these organs maybe destroyed. 
Sometimes the morbid action occurs at a joint, which is laid open, and 
the cartilage exposed ; the bones of the metacarpus, metatarsus, and 
even those of the tarsus, may be thrown off in this way, as may the 
entire foot, and, more rarely, the hand. After the expulsion of the 
bone the ulcer heals, and, in the case of the denudation of a joint, 
the cartilage adheres firmly to the integument. 

The mucous membrane, in the anaesthetic form of elephantiasis, is, 
like the skin, pale, and, in an advanced stage of the disease, insensi- 
ble ; the conjunctiva becomes dry, from retrocession and eversion of 
the lower eyelid, and frequently becomes coated with a brownish 
crust; the mucous membrane of the nares is also dry and crusted, 
and the septum frequently perforated by ulceration, but the ulceration 
never proceeds to the extent witnessed in the tubercular form of the 
disease, and the nose never becomes flattened from destruction of the 
bones. The mucous membrane of the mouth and fauces is also pale, 
insensible, and dry ; the gums recede from the teeth, and taste, as well 
as sight and smell, is lost. 

The morbid element in the ansesthetic form of elephantiasis differs 
from that of the tubercular form, in being transparent and colorless, 
instead of opaque and whitish. In the ulcers of the skin, it is repre- 
sented by the transparent, viscous secretion which is poured out in 
such quantity. In the internal organs it is found deposited in the 
subserous tissue, as in that of the lungs, liver, spleen, and kidneys ; but 



ELEPHANTIASIS. 343 

its most abundant and pathognomonic seat is in and upon the brain, 
spinal cord, and nerves, including the nervous ganglia of the sympa- 
thetic system within the abdomen. The abdominal viscera are also 
found diseased in their substance; the liver is hypertrophic, and often 
fatty; the spleen is enlarged; the mesenteric glands swollen; and the 
kidneys always more or less seriously diseased. During the local 
disturbance which occurs in the extremities, and which gives rise to an 
ulcer or a slough, or when the secretion from an ulcer is temporarily 
checked or suspended, the lymphatic glands of the groin and axilla 
become swollen, and the subcutaneous cellular tissue is rendered oede- 
matous, from effusion of the same morbid albuminous element. 

The constitutional symptoms resemble those of the tubercular form 
of the disease, but are less severe, and of longer duration. In the 
first instance, they are limited to a general feeling of heaviness and 
languor, with occasional chills, and a fixed paleness and anxious 
expression of countenance. Then the digestive organs begin to suffer; 
there is loss of appetite, sense of weight and oppression at the cardial, 
dryness of the mouth and throat, thirst, disturbed sleep, and increased 
chilliness of surface. These symptoms are most marked and undergo 
exacerbation, whenever an increase of deposition in the nervous 
centres, or internal organs, or an augmentation of the local disease is 
imminent, or whenever a suppression of secretion occurs; and they 
subside as soon as the vessels have relieved themselves of their burden 
of morbid fluids. In the course of years the powers, both of mind 
and body, are exhausted, and the patient sinks gradually into death; 
sometimes the last change is ushered in by colliquative diarrhoea and 
cramps; at others, where the kidneys have become disorganized, and 
the urine albuminous, it is preceded by coma. When the eyeball is 
destroyed by the disease, there are often severe pains at the back of 
the orbit, arid necrosis of a bone is also accompanied by deep-seated 
and often violent pains. At the same time the insensibility of the 
more superficial parts may be such, that the eye may be divided by 
the knife without the knowledge of the patient. The coldness of 
surface which accompanies the insensibility is also a characteristic 
symptom; the temperature of the hands was rarely higher than 90°, 
and frequently as low as 68°; while in the armpits and groins, it 
varied from 97° to 104°. 

The average duration of the anaesthetic form of the disease, as de- 
duced from the observation of cases in the hospital at Bergen, during 
the years 1840-47, was eighteen years and a half; and of twenty-four 
deaths that occurred during that period, two patients, between forty 
mid sixty years of age, had suffered from the disease for five and six 
years; and one, who had it from infancy, for thirty-one years. In 
twelve of the twenty-four cases the duration of the disease was twenty 
years and upwards. 

PATHOLOGY OF ELEPHANTIASIS. 

The material morbid element in elephantiasis is a viscous albumi- 
nous fluid, chemically composed of an excess of albumen, a small 



344 DISEASES FROM SPECIAL INTERNAL CAUSES. 

quantity of fibrin, some fat, and salts; this fluid concretes into a 
whitish, semi-opaque mass, in the tubercular form of disease, and 
retains its transparency in the anaesthetic form. Deposited in the 
tissue of the affected organs, it tends to their disorganization, firstly, 
by the interruption of circulation and innervation; and secondly, by 
the process of softening or dissolution. Thus, when the patches of 
erythematous skin in the tubercular form of elephantiasis were divided 
with the knife, the corium was found to be swollen and thickened, 
from the distension of its meshes by a sanguinolent fluid. When the 
tubercles were divided, the thickening of the corium was found to be 
more complete ; there was less fluid in the interstices of the fibrous 
structure, and the color of the section presented a brownish tint. 
While in a third stage, the stage of softening, the structure of the 
corium was gone, its place being supplied by a yellowish-white granu- 
lar mass, which, on being squeezed out, resembled gruel. These mor- 
bid phenomena serve, moreover, to explain the subsequent changes 
which ensue, namely, the thinness, absence of color, deficient sensa- 
tion, want of secretion and hair formation, in fact, the atrophy of the 
skin where the tubercles subside spontaneously, and the similar 
appearances which follow the healing of an ulcer, and also the copious 
ichorous discharge which is poured out when an ulcer is formed. 

In the skin, the seat of deposition is the fibrous structure of 'the 
corium, and the same in the mucous membrane. The subcutaneous 
cellular tissue is not unfrequently oedematous, and sometimes thick- 
ened from infiltration of a gelatinous or lardaceous deposit; but the 
latter never assumes the opaque character of the deposition in the 
skin. In the viscera, the deposition takes place in the subserous 
cellular tissue, and gives rise to tumors, for the most part small, but 
sometimes of considerable size. Tumors of a similar kind are occa- 
sionally found in the substance of the liver, and the eyeballs are 
sometimes destroyed by depositions which commence within the inte- 
rior of their cavity. The ovaries and the lymphatic glands, particu- 
larly those of the mesentery, participate in the morbid change. Ano- 
ther common seat of the morbid deposit is the outer coat of the 
cutaneous arteries and veins, particularly the latter, and the neuri- 
lemma of the nerves, the lardaceous deposition occupying all the 
space between and amongst the fibrils of the nerves. These latter 
observations explain the arrest of nutrition and atrophy of the affected 
part of the skin, and also the defective sensation. In some instances 
Drs. Danielssen and Boeck found the semilunar ganglia of the sym- 
pathetic system in a state of softening, and the vessels of the abdomen 
were not unfrequently in the same morbid state with those of the 
skin. The organs and tissues which were found to escape the influ- 
ence of the disease, were the deep cellular tissue, the muscles, bones, 
parenchyma of the lungs, pancreas, salivary glands, and brain and 
Bpinal cord. The blood contained an excess of albumen and fibrin, 
and, when taken from the patient during the febrile stage preceding 
the eruption, presented a small proportion of serum, which was green 
and viscous, and a large solid clot with thin, buffy coat, and frequently 
on the surface of the latter a stratum of albumen. 



ELEPHANTIASIS. 345 

In the Anaesthetic Elephantiasis, the prime seat of the morbid 
deposit is the spinal cord, and the ganglia and sheaths of the nerves. 
In the autopsies performed by Drs. Danielssen and Bdeck, the veins 
of the spinal cord were found congested, particularly at its posterior 
part; a dense, albuminous layer, several lines in thickness, was found 
between the arachnoid and pia mater; there was general infiltration 
of the membranes of the cord by albuminous fluid ; and the cord 
itself was tough, almost as hard as cartilage, and in some cases 
reduced to the calibre of a quill. The gray substance of the cord 
was of a pale, dirty yellow color, and all trace of bloodvessels, 
excepting in the middle, was lost. With such a state of morbid 
alteration of the nervous centre, the characteristic phenomena of the 
disease, the anaemia, emaciation, atrophy of the muscles and skin, 
mortification of the skin, and necrosis of the bones of the extremities, 
are easily explained. In cases where the face, nares, and mouth were 
extensively reduced in sensibility and nutrition, the eyes being in a 
state of atrophy, the Casserian ganglion was found to be distended 
with albuminous exudation. The same albuminous deposit has been 
found within the sheaths of the nerves in other parts of the body, 
giving them a swollen appearance, and explaining at once the 
destroyed innervation of the surface and extremities, and the deep- 
seated pains so common in this disease, and particularly in its later 
stages. The same transparent albuminous exudation has been found 
in the subserous tissue of the lungs and liver, and in the substance 
of the lymphatic glands. The mucous membrane is pale, and less 
apt to ulcerate than in the tubercular form of disease ; the eyeballs 
become opaque and atrophied ; there may be a small ulcer in the 
septum nasi, but the nose never falls in ; the spleen is usually hyper- 
trophied ; the liver sometimes fatty, and the kidneys always seriously 
diseased ; the pancreas and salivary glands commonly escape ; the 
blood in the anaesthetic form differs very little from that in tubercular 
elephantiasis. 

In selecting well-marked examples of the two forms of elephantiasis, 
the distinction between them is very evident ; but in slighter cases, 
there is often a blending of the symptoms belonging to the two. In 
one out of six cases, according to Drs. Danielssen and Bb'eck, the 
disease commences with anaesthesia of the hands or feet, and then passes 
into the tubercular form ; in one case in twenty, the anaesthetic form 
takes the place of the tubercular ; or aborted tubercles are developed 
in the course of the anaesthetic form. In a word, though frequently 
quite distinct, and pursuing an independent course, the symptoms of 
the two forms may be present in the same individual, or the one may- 
pass into the other ; moreover, parents afflicted with one form may 
have children in whom the other form is developed. The tubercular 
is more common than the anaesthetic form. 



CASES OF ELEPHANTIASIS. 

The opportunities of observing elephantiasis in England are neces- 
sarily and fortunately very restricted at the present day, although the 



346 DISEASES FROM SPECIAL INTERNAL CAUSES. 

disease was once a native of Great Britain. Willan remarks that he 
had only soon two instances, and my own experience does not extend 
far beyond his; but although the cases which have come before me 
are few in number, they have happily embraced the leading features 
of both forms, and have enabled me to comprehend the disease, and 
carry my experience into a wider field of inquiry, namely, into that ' 
of the existence amongst us, even now, of traces of the disease, in a 
comparatively insignificant, but nevertheless unmistakable shape. The 
cases which have been presented to me are of two kinds, imported and 
indigenous; the imported cases occurring in Europeans who have been 
born or passed a number of years in countries where the disease is 
endemical — namely, the East and West Indies and the Mauritius ; the 
indigenous cases being those who had never left this country. 

On referring to my notes, I find the cases of two young persons, 
both presenting the early stage of elephantiasis, but having the cha- 
racteristic signs of the disease well marked. They were born of Euro- 
pean parents, the one, a young lady, in the island of Mauritius; the 
other, a young man, in Jamaica ; the former was nine, the latter 
twenty-one years of age. Both had the appearance of imperfect de- 
velopment, looking considerably younger than their real age : they 
evinced a dulness both of mental and physical power, and had a pecu- 
liarly sombre and melancholy expression of countenance. 

Case 1. — The young lady had no other symptoms of general dis- 
turbance of health than listlessness, inactivity, and coldness of hands 
and feet; but the coldness was not appreciable to herself. Her hands 
were thin, the fingers long and taper, and bluish towards the ends, and 
there was a bluish or purplish hue on her lips and cheeks; the con- 
junctiva and mucous membrane of the mouth and fauces were pale, 
and the skin of her limbs was less sensitive than natural. This state 
had come on imperceptibly, and the first symptom that alarmed her 
parents, and induced them to send her to this country for a change of 
air and medical aid, was an eruption of erythematous blotches, which 
made their appearance on the limbs after a slight intermittent fever- 
ishness of some days' duration. The feverish symptoms subsided 
after the development of the eruption, but the latter had continued for 
several months, and seemed to be permanent ; for, although the 
erythematous spots gradually faded, and sometimes went away com- 
pletely, yet other spots and patches appeared from time to time, and 
kept up the complaint. On her visit to me, she had as many as twenty 
or thirty of these spots dispersed over her limbs, presenting successive 
stages of development. The spots were rounded in form, not raised 
above the level of the surrounding skin, and from half an inch to two 
inches in diameter. At their first appearance they presented a light 
crimson blush, deeper in the centre than at the circumference; in a 
few days they had a purplish tint, then a brownish-yellow tint, and 
then by degrees they faded away, without leaving any trace of their 
existence. After some months' duration of the disease, the patches 
faded more slowly, and, instead of disappearing completely, the patch 
became gradually transformed into a yellowish-brown or blackish 
stain, morphcea nigra. My patient had several of these stains on her 



ELEPHANTIASIS. 347 

limbs ; some were a little rough from desquamation of the cuticle, 
but the greater number were smooth and glossy, smoother than the 
surrounding surface, in consequence of obliteration of the lines of 
motion of the skin, and possessed of a polish of metallic brilliancy, 
from stretching and thinning of the cuticle. To the touch, the centre 
of the spots was denser than the normal skin ; they were dry, from 
arrest of function of the sudoriparous glands, and were insensible to 
a pinch or to the prick of a needle. I was unable to follow this young- 
lady's case further, but at a later period I have no doubt that the 
bronzed spots will become gradually bleached, from absorption of the 
coloring pigment ; the insensibility will increase, and the skin become 
white, and pass into a state of atrophy, morphoea alba, leuce. 

After watching this patient for two years, she grew tired of coming 
to see me, and I lost sight of her. Six years later, however, she was 
brought to me sadly changed ; the face was covered with tubercles, 
her complexion was yellowish-brown, the frowning eyebrows had lost 
their hair, the conjunctivae were anaemic and glassy, the eyelids were 
drawn widely open, the hair of her head was scanty, the lobes of the 
ears enlarged, her limbs thin and shrunken, and her hands and fingers 
wasted. A lady of title, her relative, besought me, as a boon to her 
family, that I would take charge of her, that I would take her into 
hospital, that I would find an asylum for her — in short, that I would 
take her and do as I pleased with her, and relieve her family of any 
further anxiety, or even thought of her. The poor girl was to be 
banished, might be buried, anything, provided that her family heard 
nothing of her more, except that the tomb had in reality closed over 
her. Such was my commission ; it awakened historic recollections of 
the ancient leprosy, and I was enabled to comprehend the barbarities 
with which the leper was pursued in the olden time. 

To obtain for her a home was a labor of much difficulty ; all who 
saw her shuddered at the idea of coming in contact with her ; and I 
esteemed it a piece of good fortune, when a sister of mercy of these 
modern times, a disciple of Florence Nightingale, took my poor 
patient in charge. A feeling of religious duty supported this lady in 
her task ; and without such support she must have succumbed to the 
vexations that were heaped upon her in the course of her duty ; the 
inmates of her house protested, the inhabitants of the square in which 
she lived made painful remarks ; she herself failed in health, and her 
exhausted nervous system was haunted in the night with the fancied 
presence and touch of her repulsive ward ; but she bore up through 
all. More than once I felt it my duty to say to her : Tell me when 
you can bear it no longer, and you shall be relieved ; I will find some 
other asylum for her. But religion supported her to the end ; and 
she never once failed to surround with all the comforts in her power 
the declining days of the poor leper. 

My patient died two years after this, at the age of seventeen ; she 
Buffered no pain, and seemed to have no idea of her repulsive state. 
During the later months of her life her vision was weakened ; she had 
ulceration of the larynx ; ulceration of the integument of the arms 
robbed her of nearly the whole of the skin from the shoulders to the 



348 DISEASES FROM SPECIAL INTERNAL CAUSES. 

hands ; the legs were oedematous ; the feet ulcerated ; thick gouttes of 
matter oozed from large openings in her face; and she succumbed at 
last to exhaustion, precipitated by diarrhoea, probably from ulceration 
of the mucous lining of the intestines. 

Case 2. — My patient from Jamaica was an example of a more 
advanced stage of the disease than the preceding. He was brought to 
me in the summer time, and complained of being never warm, while 
in the winter he scarcely felt the cold. The disease had first shown 
itself in the form of erythematous blotches, five years ago, after a 
winter spent in England, during which he had suffered severely from 
the cold. The blotches appeared first on the calf of the leg, and 
gradually faded away. During the following year the erythema 
attacked the lower part of the face, and spread upwards by degrees. 
A year after, patches were developed on the trunk, while the skin of 
the face, and particularly of the forehead and brow, began to be 
discolored and thickened. On presenting himself before me, the lower 
part of the forehead was thick and prominent, and marked by several 
rounded elevations or incipient tubercles, which threw the brow into 
wrinkles, and gave a frowning expression to the countenance. There 
was a similar tubercular condition of the ears, and a commencing 
rugosity of the lips and chin. The texture of the skin was coarse 
and granular, its color dusky brown or tawny, and its surface greasy 
from effusion of an excess of sebaceous substance. This latter is one 
of the occasional symptoms of elephantiasis ; and Drs. Danielssen and 
Boeck have remarked, that when it occurs, there is an hypertrophous 
condition of the sebiparous glands. The prominent, frowning eye- 
brows of my patient were almost denuded of hair, and, although 
twenty-one years of age, there was no appearance of whisker or beard. 
The conjunctiva and mucous membrane of the mouth and fauces were 
pale, and the voice husky. The trunk of the body and limbs were 
covered with tawny patches, varying in size from a mere point to 
the breadth of the palm of the hand, of an irregular figure, but. for 
the most part, rounded in form, and dry, from deficient perspiratory 
secretion. The small points were seated in and around the pores of 
the skin, as if the discoloration had commenced within the follicles ; 
and the larger patches were studded over with these smaller spots, of 
a deeper tint than the surrounding discoloration. There was no itching 
or irritation in the blotches, nor any hardening in the centre, as in 
the previous case ; but they were evidently less sensitive than the 
unaffected skin. The hands were thin, the fingers long, slender, and. 
of a leaden hue, and the skin covering them attenuated and bronzed. 
He observed that his face was more sensitive to the action of the air 
than it used to be, and that it was apt to become inflamed when 
exposed to the rays of the sun. His general health was undisturbed, 
but he complained of listlessness and indisposition to apply his mind 
to any mental pursuits. 

It has been observed that the loss of hair which accompanies tuber- 
cular elephantiasis is restricted to the parts of the body directly 
affected by the disease, for example, the eyebrows, eyelids, and the 
white patches of morphoea alba ; in these instances, owing its fall to 



ELEPHANTIASIS. 349 

the destruction or imperfect nutrition of the hair-follicles; but it has 
been also noticed, that where elephantiasis occurs in a young person, 
development is retarded, puberty deferred, and there is frequently a 
defect in the production of hair, as in the present case. I have already 
remarked that the young lady was more childlike than beseemed her 
age ; and there was also a deficiency of sexual instinct in the male. 

The previous cases are examples of elephantiasis in its incipient 
state, and developed in young persons born of European parents, but 
in a country where the disease is endemic. I will next proceed to 
the narration of two cases of Europeans attacked by the disease after 
a long residence in India. 

Oase 3. — Captain B , aged forty-three, had resided in India for 

seventeen years. Between seven and eight years back, while in 
Scinde, he observed discolored spots upon his limbs, and a dark dis- 
coloration of the skin of the face and neck. He was otherwise quite 
well in health, and prosecuted his military duties as usual. Within 
the last three or four years he had been the subject of frequent attacks 
of intermittent fever, and about two years since, these aguish attacks 
had become so frequent that he was under the necessity of coming to 
Europe for relief. He states that he was in a constant state of fever, 
with exacerbation and rigors every other day. For the relief of this 
fever he resorted to Kissingen, and put himself under a course of the 
waters of that place, which brought on a crisis attended with deter- 
mination of blood to the head. During this illness a number of fresh 
erythematous patches appeared on his limbs; his face, and particularly 
the forehead, was congested, and a crop of prominent elevations or 
tubercles was developed along the eyebrows. The fever then subsided, 
and ceased somewhat suddenly, and he has had no return of the 
feverish symptoms. About eighteen months after this attack he 
appeared before me for relief from the discolored patches on his limbs 
and body, and from the tubercular condition of his forehead. He made 
no complaint of his general health otherwise than that his hands were 
always cold, even in the hottest weather, and this he attributed to "want 
of circulation." His hands were thin, the fingers of a leaden hue, and 
the skin smooth and polished, shining with a metallic lustre. There 
were numerous dark-brown patches on his limbs, some of which were 
quite smooth, while others were raised, as though oedematous or infil- 
trated with a yellowish jelly, and apparently translucent. They were 
dry, from absence of cutaneous secretion, and some of the prominent 
patches, in which the gelatinous transudation appeared to have been 
absorbed, were collapsed and wrinkled. Along and immediately 
above the eyebrows were twelve or fourteen prominences on each 
side, of about the size and elevation of split peas; in the lower part 
of the skin of the forehead, and towards the inner end of the eye- 
brows, the tubercles were isolated ; along its outer half they were 
clustered and confluent. Upon close examination the tubercles were 
whitish and semi -transparent, and marked by the ramifications of 
several large venules, the cuticle covering them being of a dark color, 
like that of the surrounding skin. The hair of the eyebrows was 
thin, and absent on the tubercles themselves. The dusky hue of the 



350 DISEASES FROM SPECIAL INTERNAL CAUSES. 

skin of the forehead, and the heavy frown of the hairless and rugous 
eyebrows, gave a strongly-marked leontine character to the counte- 
nance. 

Case 4. — Dr. , one of the chiefs of the Medical Establishment 

of Bengal, had resided in India for forty years, and, with the exception 
of several years of suffering from hepatic disease, enjoyed unusually 
good health. He is now seventy, and the first symptoms of his 
present disease made their appearance in 1849, at the age of sixty- 
seven. He reports, that in the summer of 1850, while in Malta, he 
became aware of an occasional weakness in walking, and a benumbed 
sensation on the outer side of the right foot. Later in the year an 
erythematous blotch showed itself at the seat of the numbness, and 
was attended with a prickling sensation and a feeling of tightness, as 
of a wire fastened around the part when moving the foot. In 1851 
similar phenomena occurred in the left foot, and several new spots 
appeared on the right leg. The spots were of a dusky red color, 
rough, and dry on the' surface, tender to the touch, and accompanied 
by a feeling of tightness. A few months later the feet were very 
tender, the prickling sensation was more general, and the tightness on 
walking had extended higher up the leg. While these changes were 
in progress he began to experience a sensation of numbness on the 
side of the metacarpophalangeal joint of the middle finger, and ob- 
served a patch of redness on the next joint. In the month of January 
of the following year there was an evident numbness of the little and 
ring-finger of the right hand. 

Up to this time he had not been troubled with any constitutional 
disorder, but, about the middle of January, 1852, he was seized with 
sickness of stomach, and a fortnight later with a smart attack of fever, 
accompanied with excessive sweating, the latter symptom sometimes 
coming on without being preceded by the usual hot stage. He was 
treated with quinine, and the fever speedily gave way. At the end 
of eight days he was well ; but on the third day of the fever, and 
during the hot stage, two large, livid, cedematous-looking blotches, 
which he spoke of as resembling blebs, suddenly made their appear- 
ance on the outer border of the left wrist. After the subsidence of 
this febrile attack the sensibility of his fingers gradually returned. 
In June he had a second attack of fever, which lasted eleven days, 
being preceded by sickness; on the ninth day of the fever the numb- 
ness returned, but disappeared on the eleventh day. In July there 
was a third febrile attack of the same kind, accompanied with a burn- 
ing sensation, pain, and soreness of (he outer border of the feet/ 
increased numbness of the ring and little finger of the left hand, red- 
ness of the knuckles, pain on exposure to the slightest cold, and the 
development of a hard and inflamed swelling just above the inner 
condyle of each upper arm, in the situation of the supra-condyloidean 
lymphatic gland. During the month of August the disease continued 
steadily progressing; tubercles were thrown out on the face; erythe- 
matous spots and patches appeared on the abdomen and limbs, being 
preceded by itching and smarting when fully developed. In Septem- 
ber there was a still further increase of the disease, the whole forehead 



ELEPHANTIASIS. 351 

was studded over with tubercles ; there were erythematous patches 
within the mouth, and hard tumors developed in the subcutaneous 
cellular tissue of the forearms and back of the wrists. The three fol- 
lowing months of the year saw only a progressive advance of the dis- 
ease in every way, with increased insensibility and lividity of the fin- 
gers, and feet. 

In January, 1853, numerous large patches made their appearance 
on the back of the thighs, and several of those already in existence 
threw out a broad areola around their circumference, which gave them 
an annulated appearance, dark, and almost livid in the centre, and 
bounded by a crimson band. In April, after a hot bath of the tempe- 
rature of 104°, the face became flushed and spotted over with erythe- 
matous patches of a vivid red color, the redness of the spots on other 
parts of the skin was increased, and they became prominent from ©ede- 
matous infiltration, while those which were already prominent became 
enlarged. The symptoms now assumed a progressive character ; in the 
beginning of May, there was inflammation of the left hand and oedema 
of the' right ankle, with a sensation of extreme cold, although the part 
was hot to the touch. The face remained congested and swollen, the 
features were enlarged, and the natural wrinkles of the skin deepened ; 
the alte of the nose were remarkably distended, and hard knots, like 
tubercles, could be perceived as well as felt under the skin, at the 
outer angle of the eye, upon the temple, and upon the ears. Inflam- 
mation now appeared on the right hand, and the fingers became swol- 
len and painful, like those of the left. The deranged sensations of cold 
and pain continued in the legs and feet, spots showed themselves on the 
palms of the hands, and the oedema, which had increased in the patches, 
was now apparent in the lower eyelids. 

The preceding narrative of the case is drawn from a journal kept 
by the patient himself, and at the conclusion of this period, namely, 
on the 25th of May, 1853, he first came under my observation, his 
state being much aggravated, and the disease accelerated, as he be- 
lieved, by the treatment which had been pursued, and which consisted 
of arsenic, in large doses, for seven weeks ; then iodide of potassium, 
at first alone, and subsequently with arsenic, for another term of seven 
weeks ; then iodide of potassium, arsenic, and bichloride of mercury, 
all combined, for three weeks, until the gums became tender ; next, 
the bichloride of mercury with sarsaparilla, for seven weeks ; and 
lastly, two grains of blue pill night and morning, to keep up tender- 
ness of gums, in addition to the bichloride of mercury and sarsapa- 
rilla. It was after this severe course of treatment, extending in time 
from August 13th, 1852, to April 20th, 1853, that he first consulted 
me ; and I could not but agree with him in thinking that the treatment 
had tended to hasten rather than check the progress of the complaint. 
I was glad, however, to have the opportunity of seeing the results of 
this active plan of treatment, conducted, as it had been, by a most 
able physician; and I felt that little hope of benefit could be looked 
for from such a course, although consisting of remedies which, a priori, 
and without the experiment, I should have looked upon as best calcu- 
lated to bring about a cure. 



352 DISEASES FROM SPECIAL INTERNAL CAUSES. 

The history of the patient, while under my care, was a progressive 
advance of the disease, both in eruption and diminution of sensation, 
until the month of August, when a state of extreme dulness, heaviness, 
and lethargy came on, accompanied with febrile sj'mptoms, and con- 
tinued for several weeks. From this attack he gradually recovered, 
and two months later had regained strength, appetite, and a pow T er of 
applying his mind to reading. The oedematous tubercles on various 
parts of his body were becoming smaller; many of the brown-colored 
spots were fading ; and there was a slight increase of power over the 
muscles of his hands and lower limbs. He could walk across the 
room with the aid of a servant, and had some feeling in his feet; but 
his hands were still very sensitive to the influence of cold, and he was 
obliged to continue the use of warm gloves to protect them. 

My treatment during this interval was, in the first place nitro-muri- 
atic acid with gentian ; then a course of decoction of the woods with 
Donovan's solution ; then a return to the nitro-muriatic acid and gen- 
tian, with the addition of iron ; during the febrile attack, ordinary an- 
tiphlogistic remedies, and after its cessation, ordinary tonics. ' I had 
so little faith in specific remedies, that I felt no inclination to resume 
them, and I cannot say that any advantage appeared to result from 
the decoction of the woods. 

The nephew of this gentleman, himself a physician, reporting the 
patient's state of health in March, 1855, observes: " By using the 
warm salt-water bath, and residing some months on the sea-coast, he 
so far regained the strength of his limbs that he was able to walk a 
mile alone, and no appearance of spots was visible, with the exception 
of a few upon the abdomen." 

Case 5. — Another case, which I believe to have been one of anaes- 
thetic elephantiasis, occurring in a person who had never been out of 
this country, came under my notice in 1849. Dr. Nathaniel Jarvis 
Highmore, of Bradford, Wiltshire, in a letter to me, introducing the 

patient, says : " Mrs. L , married at the age of twenty, her health 

previously, and for twelve months after, being good. About May, 
1842, she became, from family circumstances, the subject of great 
mental anxiety, weak, poorly, and complained of severe pain in the 
left side, immediately below the heart ; the skin in a few days became 
dark, discolored in patches, and swollen, especially the hands and feet. 
After a short time the skin about the throat and chest apparently con- 
tracted, giving the sensation of a person tightly grasping it." Some 
months later, Dr. Highmore describes her state as being one of "de- 
pression bordering on mania; she was sleepless, and refused either to 
speak or eat." Both hands and feet were at this time much swollen, 
but she retained perfect command over them; later, however, they be- 
came stiffened. Vapor baths were. administered to her with decided 
injury, and equally injurious was a course of mercurial medicine. Dr. 
Highmore first saw her in 1846, at which time she was still under the 
influence of mental anxiety. She became depressed from the slightest 
cause ; her hands and feet were always cold, and if she were excited, 
they, as well as her nose, presented a purple tinge. The skin of the 
arms, face, throat, chest, and neck was hard and contracted, and of a 
dark olive color. 



ELEPHANTIASIS. 353 

When this patient appeared before me, she was extremely emaciated, 
and her skin so much contracted as to appear too small for her body ; 
her lower eyelids were drawn down, exposing more of the eye than 
usual ; her features were lengthened, and the lower lip had fallen away 
from the mouth, showing the teeth and gums. Her fingers were bent 
and contracted, and there were several sore places upon them, occa- 
sioned by ulceration ; the sensibility of the skin was deadened, and her 
movements were effected with difficulty. 

This patient died the year following of acute bronchitis, "no change 
having taken place in the appearance or functions of the skin." 

Etiology. — The cause of elephantiasis is an animal poison gene- 
rated in, or received into the blood, accumulated therein, probably by 
a process analogous to fermentation, to the point of saturation, then 
acting as a morbid stimulant or irritant, and giving rise to certain 
phenomena which have for their object the elimination of the poison, 
either by the natural emunctories, or by deposition in the tissues of 
the body, the surface tissues in the tubercular form, the nervous cen- 
tres in the anaesthetic form, or by the discharges from ulcers. The 
nature and origin of the poison are wholly unknown ; certain condi- 
tions of the human body, and of the elements around it, must have 
co-operated at its first production, and those conditions no doubt con- 
tinued for a time, and may still be in action more strongly in some 
countries than in others, for the maintenance of the poison, and for 
the perpetuation of the disease. This constitutes the spontaneous or 
endemic origin of elephantiasis ; and in this point of view we may re- 
gard, as springing from such a source, the two instances of Europeans, 
cases 3 and 4, previously narrated. 

Those gentlemen resided for some years in a country in which this 
disease prevails, and were afflicted with it in consequence ; and a 
similar consequence may be entailed on any one similarly placed. 
Fortunately, elephantiasis is not very common in India, and, there- 
fore, we may suppose that the causes giving rise to it are weak ; but 
in the Mauritius, and particularly in Norway, they are still strong, 
and new residents in those parts are in danger of being attacked by 
the disease. Several of the European settlers in the Mauritius are 
now suffering severely from elephantiasis, chiefly of the tubercular 
kind ; and Drs. Danielssen and Bb'eck mention the case of a naval 
officer who lived for a short time in Norway, and was afterwards afflicted 
with the disease. 

The doctrine of infection and contagion, as applied to elephantiasis, 
has long been abandoned ; several of the older medical authors ex- 
pressed their doubts as to its communicability by this means, and 
modern authors are all agreed in denying it; and not only is this the 
prevailing opinion, so far as ordinary social intercourse is concerned, 
but it is also denied that a husband can communicate the disease to his 
wife, or a wife to her husband, or that a nurse can convey the disease 
to an infant by suckling. Thus the revulsion of opinion is complete, 
and admits of no origin for the disease but that already stated, and 
hereditary transmission. A European gentleman from the Mauritius, 
who lately consulted me, stated that he had resided in the island for 

23 



354 DISEASES FROM SPECIAL INTERNAL CAUSES. 

twenty-nine years ; he had married a native lady, who, with her five 
children, was perfectly free from any trace of disease; but that, within 
the last twelve months, symptoms of an undoubted character had ap- 
peared in himself. I did not hesitate to say, that I believed marriage 
had no share in producing his present symptoms, and that the disease 
originated in endemic causes alone. His case was interesting, as pre- 
senting the earliest phase of the complaint ; he was feeling strong, and 
well, and perfectly free from pain or inconvenience of any kind ; but 
there was numbness of his feet and legs, and part of his arms, and he 
had scalded himself accidentally with the steam of a boiling tea-kettle, 
without being aware of any sensation. 

With regard to the second and more frequent mode of propagation 
of the disease, namely, hereditary transmission, the same variation of 
results is met with as is found in all other natural phenomena. Leprous 
parents may have all their children affected, or one or two out of an 
entire family ; or the children may escape entirely. The same may 
take place where the mother or father only is diseased ; but it would 
seem that transmission through the mother is more constant than on 
the side of the father. Again, the disease may pass over several suc- 
cessive generations, and show itself unexpectedly when the remem- 
brance of such an inheritance is forgotten. 

Elephantiasis may occur at any period of life, but is less frequent 
in infants than in children beyond the age of seven, and most com- 
monly does not show itself until after the period of puberty. . It 
is also more common in the male than in the female sex. When 
it occurs before puberty it is apt to cause a suspension of sexual de- 
velopment. 

Amongst other conditions favoring the occurrence of elephantiasis, 
is a damp and humid atmosphere. The disease took its origin, as we 
have seen, on the marshy banks of the Nile, and its habitat still con- 
tinues to be the banks of rivers ; islands, as Mauritius, Madagascar, 
Madeira, the Greek Islands, the Crimea, Iceland; and sea-coasts, as 
those of the Black Sea, Mediterranean, and, in particular, the coast of 
Norway. Temperature is obviously an uninfluential condition, for the 
disease at the present time evinces its greatest activity in India, the 
islands of the Indian Sea, and on the coast of Norway. 

We may pass over those speculations of human ignorance which 
attributed the origin of elephantiasis, one while, to divine wrath as a 
punishment for sin, and another while, to divine favor, securing to the 
sufferers religious honors. 

The known animal poisons are comparatively few, and the laws 
which govern them being the same, or nearly the same, we are not 
surprised to find that elephantiasis has been attributed to the poison 
of syphilis, or rather, that elephantiasis, being the earlier of the two, 
was supposed to pass into syphilis ; and it is a curious fact, that syphilis 
first began to attract attention in Europe when elephantiasis was on 
the decline. The points of resemblance between elephantiasis and sy- 
philis are very striking and very remarkable, but hardly more so, per- 
haps, than between syphilis and other diseases originating in an animal 
poison ; and therefore it would be unphilosophical to infer that there 



ELEPHANTIASIS. 355 

was originally but one animal poison from which both diseases have 
sprung. It would be as correct, and equally probable, to assume that 
two animal poisons existed at the same time, the one being the poison 
of elephantiasis, the other, that of syphilis ; and that, existing together, 
for a time at least, their symptoms were confounded by the early his- 
torians and early medical writers. At the present day, even, I meet 
with diseases of the skin which I am at a loss to classify under one or 
the other poison, although to one of the two they undoubtedly belong. 
Diagnosis. — Elephantiasis may be confounded with constitutional 
syphilis, chloasma, melanopathia, leucopathia, anaesthesia and paralysis 
from ordinary causes. The muddy skin, suffused eyeball, dull-red or 
copper-colored patches, congested fauces, even the tubercles and 
enlarged venules on the surface of the skin, all belong equally to 
syphilis and elephantiasis, at a certain stage of its course ; but the 
pathognomonic signs of elephantiasis are, the defective sensibility of 
the skin, the thinning and numbness of the fingers and hands, and the 
history and duration of the complaint. In the first of the cases before 
narrated, the dull, purplish-red patches, even with the skin, and leaving 
behind them smooth, brownish, or bronzed stains, more or less insen- 
sible to the action of irritants, although pointing to the suspicion of a 
morbid poison, were totally unlike hereditary syphilis, and could not, 
from the age of the patient, as well as from the absence of other symp- 
toms, belong to the secondary period of acquired syphilis. The doubt- 
ful aspect of the eruption would lead the mind to elephantiasis as the 
only other known disease which could produce similar appearances. 
In the second case, the body was covered with patches exactly resem- 
bling chloasma, and, but for the other symptoms of elephantiasis, might 
have been taken for that' affection. In chloasma, however, the skin is 
generally dry, and roughened by a furfuraceous desquamation, besides 
being more or less irritable ; but these patches were smooth, moistened 
by sebaceous secretion, unaffected by itching, and clearly less sensitive 
than the surrounding skin. Still, the distinction between them was 
such as could only be appreciated by the experienced eye, and the 
diagnosis might have remained uncertain but for the appearance of 
the fingers and hands, the tuberculated and thickened skin of the face, 
and the frowning and alopeciated brows. The third case was remarka- 
ble for a settled chronic character, which does not belong to the more 
transient syphilis ; the tubercles on the eyebrows were hard and per- 
manent, the patches on the limbs were darker, more leaden, and more 
polished than the copper-colored stains of syphilis. By the same 
characters, also, they were unlike chloasma. Then there was the 
deficient sensibility, the chilled surface, the cold extremities, which 
pointed specially to the real disease. In the fourth case, I recollect 
having the impression given me, on the first glance at my patient, of 
syphilis ; the dusky-reddish stains, sprinkled thickly over the face, the 
Blightly-raised tubercles on the forehead and temples, the muddy skin, 
and diffused eye, all denoted syphilis. But when I saw the attenuated 
fingers, and broad bronzed patches on the arms, some oedematous, and 
others shining with metallic lustre, and detected the coldness and 
numbness of the hands, I discovered my mistake. My first questions 



356 DISEASES FROM SPECIAL INTERNAL CAUSES. 

were suggested by the coup oVoeil thrown on my patient at first sight ; 
but I soon changed my attitude of interrogator for that of listener, and 
was glad to be taught the curious phenomena and progressive history 
of the complaint. In a word, anaesthesia is the diagnostic character as 
well of tubercular as of anaesthetic elephantiasis, the difference being 
one of degree only. In tubercular elephantiasis, the morbid disposi- 
tion seems to take place in the peripheral nerves alone, while in the 
anaesthetic form it occurs in the nervous centres ; in the former, the 
numbness, insensibility, defective nutrition, and atrophy, are slight, 
in the latter tljey are extreme and fatal. 

In comparing elephantiasis and syphilis, it is not uninteresting to 
observe the close resemblance in pathological phenomena which exists 
between the two diseases. The tubercles of both are accompanied by an 
enlargement of the cutaneous venules, or rather by a development of 
venules where they normally do not exist ; in both, the tubercles result 
from the transudation of an albuminous fluid of jelly-like appearance; 
both occasion a disorganization, apparently by solution, of the structure 
of the skin; and both, as a consequence, leave behind them an atro- 
phied state of that membrane when they disappear, as they are wont to 
do, by interstitial absorption. Also, when they pass into a state of 
ulceration, both give rise to ill-conditioned, corroding ulcers, which 
tend to eliminate the poison from the blood. 

The distinguishing character between morphoea alba and leuco- 
pathia, on the one hand, and morphoea nigra and melanopathia, or 
chloasma, on the other, may be taken to be the presence or absence 
of sensation as well as of color, and the state of nutrition of the affected 
skin. In morphoea, the companion and sometimes the sole repre- 
sentative of elephantiasis, there is always, in association with altered 
color of the skin, defective sensibility, suspended nutrition, and more 
or less disorganization of structure. In morphoea nigra there is a 
temporary increase of secretion, which, however, soon fails; and in 
morphoea alba there is arrest of secretion and hair formation. 

Prognosis. — In endeavoring to form an opinion as to the issue of 
elephantiasis, a question of much consequence, as affecting the hopes 
of the patient and the exertions of the physician, we derive very little 
aid from the writings of the ancients, since by them so many cutane- 
ous affections were included under the general head Leprosy, that it is 
impossible to determine when the real elephantiasis is under considera- 
tion, and when some other and more curable affection. Thus, the 
sacred writings, usually exact and accurate in their description of 
events, are so confused on the subject of elephantiasis as to require to 
be put out of the pale of reference when treating on this subject, and 
the pages of the Greek and Arab authors are equally uncertain. The 
prevailing opinion of the ancient writers, as well as of many of the 
moderns, is, that elephantiasis is incurable, or, to a certain and very 
limited extent, susceptible of cure. While, on the other hand, we have 
before us the fact that the disease has ceased, in other words, has 
become cured, in countries that it once ravaged, that the cure has 
been progressive and complete, and that it has followed the course 
taken by the malady in its progressive march. That the cause may 



ELEPHANTIASIS. 357 

have lost its power in the countries once afflicted is quite true, but 
that it has ceased entirely is not so, for examples of the disease still 
continue to be met with in its old haunts, and there is no reason why 
at some later day it may not regain all its old power, and become a 
second time one of the epidemic pestilences which are permitted from 
time to time to affect mankind. Therefore, while, on the one hand, 
we have the opinion of the incurability of elephantiasis, we have, on 
the other hand, the proof of its curability in a race, however little such 
reasoning may be applicable to the individual. 

Amongst other conditions which may influence the prognosis of 
elephantiasis, are its hereditary or accidental origin, and its acute or 
chronic invasion. When the disease is accidental in its origin, it 
offers a better chance of cure than when hereditary, and may be pro- 
nounced to be susceptible of cure ; and when the disease is acute, it 
may be expected to yield more readily to treatment than when insidi- 
ous in its attack and chronic in its progress. Moreover, the new 
light and new vigor thrown into the subject by Drs. Danielssen and 
Bb'eck lead us to hope that much more may be done in the cure of 
this affection than has been heretofore supposed ; and that elephanti- 
asis may be removed from the category of incurable into that of cura- 
ble complaints. 

Treatment. — The treatment practised by the early physicians in 
this disease appears to have been founded on the principles of a 
rational medicine, and to the present day we have made little progress 
beyond that point, having simply glided from a rational expectant to 
a rational empirical system. In adopting this latter system, we have 
perhaps attained all that, for the present at least, we may hope to 
accomplish, and our energies will be better employed in being devoted 
to the perfection of this plan than in seeking farther into the obscurity 
of experimental medicine. Aretseus, who has left so excellent an 
account of elephantiasis in his writings, lays down as the proper plan 
of treatment, the practice of venesection, followed by the use of purga- 
tives, diluents, baths, and inunction with fat, assisted by a plain, nutri- 
tious, and wholesome diet, accompanying the latter, if the powers of 
the constitution be reduced, with wine. The purgative most preferred 
is colocynth ; the diluent, milk, attenuated with water ; and amongst 
other medicinal substances employed, are, decoctions of simples, par- 
ticularly the plantain ; and the flesh of serpents, which was held in 
high repute by the ancients, and, when properly prepared, seems to 
have made a very agreeable article of diet, corresponding with the 
turtle soup of the present day. Other remedies recommended by 
Aretseus, are, the plant called sideritis (ironwort), the trefoil, sorrel, 
and iris; alum, sulphur, and carbonate and phosphate of lime, under 
the form of elephant's teeth. The fats used for inunction were those 
of the panther, lion, and bear. 

iEtius follows the general plan of treatment described by Aretaeus, 
adding, that amongst the Indians it was customary to exhibit as a 
medicine the urine of the ass, probably on account of its diuretic 
effects, and prescribe as an article of diet the flesh of the crocodile. 
Serpents and reptiles seem to have acquired their reputation in this 



358 DISEASES FROM SPECIAL INTERNAL CAUSES. 

and other diseases in which the skin is affected, from their periodical 
exuviation of the cuticle, and the magistral inference that their flesh, 
partaken by man, would enable him to throw off, by a similar process 
of exuviation, the sordid covering of morbid secretions and scales 
which is apt to form in these diseases. 

Paulus iEgineta, pursuing the same course of treatment, recom- 
mends its adoption three or four times a year. To the purgatives 
already in use he adds aloes and white hellebore, and suggests the 
administration of an emetic, if needful. He also mentions, in his list 
of remedies, squills, cummin, calamint, hartshorn, theriac of salmis, 
and theriac of vipers. As a part of the hygienic plan of regimen, he 
prescribes gestation, vociferation, friction, and gymnastic exercises, 
particularly leaping. The body is then to be anointed with the fat of 
some animal, as of the boar, wolf, goat, or bird, or with butter. After 
inunction the patient should betake himself to the bath, and be well 
rubbed with some stimulating juice or spirit, such as fenugreek, or 
gum ammoniac dissolved in vinegar ; and, after the bath, he is to be 
anointed with a solution of gum ammoniac and alum in white wine, 
or with some gently stimulating and aromatic oil, such as that of 
myrtle. 

Rhazes, the Arabian physician, commences his treatment with 
emetics, and reserves venesection for cases of severity or of long 
standing; he combines turbith (convolvulus terpethum) with colo- 
cynth for a purgative, and favors excitation of the skin by means of 
friction and hot baths, and further by the help of a liniment composed 
of onions and fennel, or of a lotion of strong acetic acid, in which 
madder-root has been for some time digested. If the powers of the 
constitution be reduced by the treatment, he recommends the use of 
good white wine. 

Amongst modern authors, Schilling, who had considerable oppor- 
tunities of experience in the treatment of elephantiasis, advocates a 
modified method applicable to the different periods of the disease. 
He commences by enjoining a moderate and unstimulating diet, 
consisting of bread, broth, and vegetables, and abstinence from milk. 
He prescribes laxatives, carefully avoiding mercurials ; and if there 
be signs of plethora, he administers purgatives, and takes blood from 
the arm. Exercise he considers important, as a means of promoting 
perspiration, and rousing the patient from the state of apathy into 
which he is liable to fall ; and he further acts upon the skin by 
means of diluents and hot baths, recommending the latter to be used 
carefully in advanced stages of the complaint, as being apt to occasion 
palpitations and faintings. The diluent remedies with which he pro- 
poses to dilute the humors are emollient and demulcent drinks, as 
barley-water, gruel, decoctions of mallow and pellitory ; with infusions 
or decoctions of gently stimulating or alterative herbs, such as 
agrimony, ground ivy, fumitory", southernwood, veronica ; and mild 
aperients, as senna and rhubarb warmed with aniseed. He recom- 
mends these drinks to be taken in quantities of eight pints in the 
day, and continued for six weeks at a time, and he states, as the 
effect of the treatment, that the secretions of the bowels and kidneys 



ELEPHANTIASIS. 359 

are regulated and brought into a healthy condition. After the above 
preparatory course of six weeks, he recommends the employment of 
stronger alteratives and sudorifics, such as decoction of saponaria, 
sarsaparilla, squinanthus, contrayerva, serpentary, pimpernel, rapun- 
tium, zedoary, sassafras, juniper, scolopendrium, holy thistle, pareira 
brava, and drinks of verjuice. He maintains a strict diet, and if 
nausea supervene, he diminishes the dose of the remedy, or suspends 
it for a while. This, like the former course, he continues for a period 
of six weeks, and, as the state of the patient or of the disease indi- 
cates, he bleeds, purges, or adds tonic extracts to the preceding 
decoctions, such as fumitory, holy thistle, smaller centaury, pimpernel, 
arum, and wormwood. During the sudorific course he cautions the 
patient to avoid cold, lest it check a critical perspiration and induce 
diarrhoea, and he also suggests a cautious administration of purga- 
tives, adding to those already mentioned, namely, senna and rhubarb, 
— aloes, scammony, and the aperient salts of potash and soda. He 
prohibits acids and spirits during the treatment, as calculated to excite 
febrile action, but allows a more nutritive diet, and a little good wine, 
if the constitution exhibit signs of exhaustion or debility. 

The treatment should be pursued for some time after the patients 
have recovered, and be discontinued by degrees. The skin should be 
restored to its proper state of tone by spirituous washes and aromatic 
fumigations, and, after his cure, the patient should carefully follow the 
prescribed rules of diet and exercise. 

In a case treated successfully by Baumes, there were taken three 
hundred baths in the course of a year ; the chief remedies were 
demulcent, diluent, and sudorific drinks, including asses' milk, and 
the regimen was nutritious and unstimulating. 

Specific remedies, as opposed to the rational expectant system of 
treatment above laid down, have gained few supporters and little 
credit. The mineral specifics that have been tried from time to time 
are, mercury, antimony, arsenic, iodine, zinc, and gold. Drs. Daniels- 
sen and Bbeck have had little experience in these remedies, their 
attention having been chiefly given to the physiology and pathology 
of the disease. Mercury, they say, has largely divided the opinions 
of physicians, because their diagnosis was inaccurate ; and, according 
to those who are known to have had experience of the disease, both 
that mineral and its compounds have been found to be not merely 
useless, but also injurious. The chloride and bichloride of mercury 
have generally given rise to vomiting and diarrhoea difficult to check, 
or, failing this, have produced dyscrasis of the blood, a spongy and 
bleeding state of the gums, and a scorbutic state of the surface 
.membranes. Antimony, t\\e primum mobile of Paracelsus, had great 
weight with the older physicians, in the fourfold capacity of purgative, 
sudorific, diuretic, and alterative; but it is of little if any value in 
elephantiasis. The preparations of iodine Drs. Danielssen and Bbeck 
found to produce a burning sensation, with pain and swelling of the 
skin, in tubercular elephantiasis, when given in ordinary doses ; but 
no such inconvenience, when the iodide of potassium, in doses of a 
grain or a grain and a half, was administered. In the latter case, a 



360 DISEASES FROM SPECIAL INTERNAL CAUSES. 

slight decrease of the tumors was observed after a long period of 
continuance of the remedy, but the improvement did not last. In 
the anaesthetic form, the iodide of potassium relieved the pains in the 
bones which accompany this form of the disease ; and the same effect 
resulted from the use of the bromide of potassium. Of the prepara- 
tions of gold, these gentlemen had no experience ; they made trial of 
the chloride of zinc without benefit, and Donovan's solution was 
administered to seven patients, in increasing doses, and for a long 
period, without utility. Four of these patients suffered under the 
tubercular, and three under the anaesthetic, form of the disease. Of 
arsenic, they speak in terms of equal discouragement, and in a manner 
to suggest the doubt as to whether it could have been properly and 
carefully used, to produce the effects which they mention. One 
preparation which they enumerate, the arseniate of copper, seems to 
have given rise to a succession of painful symptoms affecting the 
abdominal viscera. 

The vegetable specifies which have gained a reputation from time to 
time are, black hellebore, lauded by Aretgeus ; pennyroyal, praised 
by Pliny ; the plantain, esteemed by Celsus ; the anabasis aphylla, a 
plant which grows on the shores of the Caspian S-ea, commended by 
Gmelin and Pallas, but not valued by Martius ; the asclepias gigantea 
of India, hydrocotyle asiatica, dulcamara, mezereon, aconite, conium, 
ledum palustre, &c. 

The animal kingdom has contributed specific remedies from the class 
of reptiles, saurian, ophidian, and chelonian ; and from the class of 
insects, cantharides. The latter remedy has acquired a false credit, 
probably from error of diagnosis, some form of common lepra having 
been mistaken for this disease. Drs. Danielssen and Boeck make the 
same remark with regard to tar, which has also, and with little pre- 
tence, been admitted among the remedies for elephantiasis. 

Reverting for a moment to the treatment of this disease pursued 
during the middle ages, we find it, as at the present day, displayed to 
us under the three aspects which constitute a rational expectant 
medicine, namely, hygienic, dietetic, and medicinal. In its hygienic 
aspect, fresh air, sufficient exercise, physical and moral, baths for 
cleanliness and to invigorate the skin, are as necessary now as they 
were then. In a dietetic point of view, a nutritive, unstimulating diet 
is one of the first recommendations at present, as well as in the past ; 
and medicinally, diluents, laxatives, and alteratives, are almost merged 
in the general consideration of diet. Then there remain only special 
emergencies, which must be met by special remedies, and the appli- 
cation of those new aids which the light of science has made obvious 
to us, and those truths which she has taught us in later times. In 
respect of air, an inland residence lying high and dry, is more desir- 
able than that of a river, lake, or the sea ; for it is in the latter situa- 
tions that elephantiasis is chiefly found. The plough and the new- 
turned earth would probably supply the double requisite of the best 
air and good exercise. In respect of baths, we have no need at the 
present day to inquire the nature of the fluid of which it should 
consist. The plain water-bath is as good as that of milk, and better 



ELEPHANTIASIS. 361 

far than the bath of blood in which the monarch of Egypt was wont 
to seethe his leprous limbs. As diet, a judicious blending of the 
animal and the vegetable seems that which is best fitted to man, in 
disease as in health ; it is that which his tastes select ; it is that which 
the naturalist predicates, from the structure of his teeth, and confor- 
mation of his stomach, he was born to. We may, therefore, afford a 
smile of pity at the contrariety of opinions that exist with regard to 
the nature of the diet employed, a contrariety as great as the varied 
tastes of man ; one while, the diet should be wholly vegetable ; now, 
to consist alone of antiscorbutic plants, to the exclusion of the cerealia 
and farinacea ; then, to be chiefly of the latter class ; another while, 
it should be milk ; then, no milk ; now, no fat, although the cod-liver 
oil is a remedy of acknowledged excellence ; then, asses' flesh, and 
so on, until the mind is bewildered. But, from this very contrariety, 
we are warranted in drawing the conclusion, that a simple, moderate, 
and unstimulating diet is not only judicious, but necessary. 

Amongst the specific remedies advocated in the treatment of 
elephantiasis, is one that I would fain have omitted all reference to, 
and I only mention now to condemn, namely, castration. Under the 
impression that the stimulus given to the blood by the generative 
system was an excitant of the disease, patients have relieved them- 
selves of these glandular organs, but without any benefit whatever ; 
and the combined opinion of all modern authors is opposed to the 
barbarous practice. 

To resume the practical consideration of the remedial history of 
this disease, I may now mention, that in 1844, Drs. Danielssen and 
Bbeck projected a plan of treatment which was found more successful 
than any which had been pursued up to that time. They thus describe 
their plan : 

Considering elephantiasis to be a disease depending on dyscrasis of 
the blood, we were of opinion that the treatment should be directed 
against the abnormal composition of that fluid ; with which object, 
we prescribed a regular diet, together with cod-liver oil, the iodides of 
potash, iron, and mercury, the bromide of potash, and sulphur baths. 
As for arsenic, fearing it might give rise to indurations of the abdo- 
minal viscera, we have used it sparingly, and in very small doses. Thus 
far, the treatment is the same for both forms of the disease. Turning 
now to the tubercular kind, we endeavor to follow the method 
pursued by Nature in the removal of the tubercles ; and perceiving 
that her process consisted in softening and subsequent absorption, we 
had recourse to means adapted to bring about the same result. We 
sought to subdue the morbid state of the skin, and reduce its conges- 
tions, partly by frequent bleedings, and partly by stimulating the 
mucous membrane of the alimentary canal. For the latter purpose 
we had recourse to sulphate of magnesia, arsenic, or the tincture of 
cantharides. As a local treatment of the tubercles, we employed the 
acid nitrate of mercury (hydrargyri aitratis, one drachm; acidi nitrici, 
two drachms) for their destruction. Where they were less in size, and 
situated on the face, we pencilled them daily, or every other day, 
with a caustic solution of potash (potassse fusye, one drachm ; aquae 



362 DISEASES FROM SPECIAL INTERNAL CAUSES. 

destillatae, two drachms) ; and where they were scattered generally 
over the body, we had recourse to caustic and sulphuretted baths, 
the caustic bath being composed of six or eight ounces of carbonate 
of potash, and an equal quantity of quicklime, mingled with the 
water; the sulphuretted bath, of five or six ounces of sulphuret of 
potash. The patients were kept in a bath for a period varying from 
one to three-quarters of an hour ; the head was repeatedly dipped, and 
after each dip was deluged with cold water ; and the bath was re- 
peated daily, or every other day. Sometimes the caustic bath gave 
rise to superficial ulceration of the tubercles ; when the ulceration 
was slight, the baths were continued, but when it became greater, they 
were suspended for awhile. We also found caustic potash of service 
in those cases of tubercular deposition within the larynx which some- 
times give rise to asphyxia ; we combined the potash with honey, and 
applied it by means of a brush to the epiglottis, and even to the 
isthmus of the larynx. A paroxysm of cough succeeded the applica- 
tion, but each time the respiration became easier, and, after a while, 
the symptoms of suffocation subsided. ' 

In the anaesthetic form of the disease, we directed our attention 
chiefly to the nervous centres, and sought to neutralize or interrupt 
the existing morbid action by means of cupping in the region of the 
vertebral column, and counter-irritation by means of tartarized anti- 
mony ointment rubbed into the incisions, or an ointment of iodide or 
bromide of potash, or by moxa. In a number of cases treated in this 
way, we were enabled to determine that the several remedies already 
mentioned had a decidedly favorable influence on the disease, although, 
from the incompleteness of our experiments, none were perfectly cured. 

In illustration of this method of treatment, Dr. Danielssen adduces 
the two following cases: 

A tailor, in whom the disease was hereditary, suffered from elephan- 
tiasis in its compound form, tubercular and anaesthetic. He was 
treated by Dr. Danielssen, and got well. Twelve months after, he 
suffered a relapse, from cold, and the disease assumed the pure anaes- 
thetic form. There was insensibility of the skin of the extremities, 
particularly the hands, and an increased and painful sensitiveness of 
the deeper parts, especially of the fingers, to such an extent that the 
latter were bent, and he was unable to hold a spoon. He was treated 
for this attack with a three months' course of iodine and bromide of 
potassium, and with decided benefit ; the excessive sensitiveness of the 
fingers had subsided, and given place to insensibility, and he was 
unable to feel his needle. He was thin and emaciated, his cheeks were 
pale and flabby, and his skin dry and inelastic. Dr. Danielssen now 
saw him. He continued the iodide and bromide of potassium, ordered 
cupping along the vertebral column, and subsequently, the application 
of the moxa. The patient improved rapidly, his fingers became 
straight and recovered their flexibility, the sensibility of the skin 
returned, his face acquired the aspect of health, and in four months he 
was enabled to resume his occupation. 

The second case was that of a man aged twenty-four, whose body 
was covered with scattered tubercles from head to foot, some of which 






ELEPHANTIASIS. 363 

occupied the deeper part of the skin, others were prominent, some 
were in a state of softening, and a few were ulcerated and covered 
with crusts. His face was swollen and livid; the tubercles on its 
surface were hard and bluish, the eyebrows were in great part gone, 
and whitish tubercles were apparent in the nasal fossae. There were, 
besides, oedema of the legs and feet, and a swollen state of the inguinal 
glands. The disease had commenced three or four years previously, 
by an eruption of reddish spots, which first broke out on the arm, 
and subsequently on other parts of the body ; the red spots becoming, 
at a later period, the present tubercles. He knew no cause for the 
attack, excepting that he had been frequently exposed to cold and 
rain, and had often slept in his wet clothes. His progenitors and 
family were entirely free from the disease, and, saving the above, he 
had no other symptoms than occasional pains in the legs. 

In the month of April he was bled to twelve ounces ; five minims 
of Fowler's solution of arsenic were given twice a day, half an ounce 
of cod-liver oil three times a day, and a sea-bath four times a week. 
In May the bleeding was repeated to ten ounces; he was cupped with 
eight glasses on the legs, and the Fowler's solution was increased to 
eleven drops, then thirteen, then fifteen. In June he was bled to 
twelve ounces ; cupped with six glasses on the legs ; the arsenic was 
stopped early in the month, having given rise to pains in the abdomen 
and cough ; and a little more than a grain of iodide of potassium was 
administered every two hours, for pains in the legs and soles of the 
feet, which came on chiefly at night. In July he was twice cupped in 
the vertebral region, each time with six glasses ; and the cod-liver oil 
was discontinued, having excited disgust. In August the proto-ioduret 
of mercury was given for eighteen days ; at first, half a grain, subse- 
quently, one grain twice a day, for the purpose, apparently, of hasten- 
ing the healing of the ulcers, and removing a thickening which had 
been left in the cicatrices, together with the thickening and infiltra- 
tion of the integument of the legs. These objects were, in a great 
measure, gained, the thickening of the cicatrices and infiltration of the 
skin of the legs were removed, but the ulcers took to bleeding, periodi- 
cal pains occurred in the legs, and pains in the teeth. After the ces- 
sation of the mercury, the ulcers progressed rapidly. In September 
the iodide of potassium was given up, cupping on the back was 
repeated several times, with the view of restoring the sensibility of 
the hands and feet, and, for the same object, baths, containing sulphuret 
of potash, and the caustic bath of carbonate of potash and quicklime 
were ordered ; at first, the sulphuretted bath daily, then in alternation 
with the caustic bath, and later still, the caustic bath increased in 
strength (eight ounces of lime and eight ounces of potash). In Oc- 
tober he reported himself as feeling better than for years before ; 
he had a desire for work, and, with the exception of a bluish tint of 
complexion, looked fresh and animated. The baths were given up; 
but, as a little dulness of feeling still remained in the fingers and 
toes, a moxa of the size of a crown-piece was placed near the spine, 
between the sixth and tenth vertebrae. In November the moxa was 
kept open by means of from sixteen to twenty peas, the sensibility 



364 DISEASES FROM SPECIAL INTERNAL CAUSES. 

was almost completely restored, but lie had still a difficulty in picking 
up small objects such as needles. In December sensibility was perfect; 
he had no pains of any sort, he was active, and returned to his home, 
although against the wishes of his physician, who still wished to ob- 
serve his progress, and anticipate any chance of relapse. 

Early in the treatment, as early as May, the tubercles had com- 
menced to diminish in size, and their diminution was progressive to 
the end of the treatment, when they had disappeared entirely, leaving 
behind them, however, a bluish and apparently deep-seated discolora- 
tion, — the skin of the part being thinner than natural. They were at 
first painted with the strong caustic solution, and subsequently with 
the acid nitrate of mercury, which caused absorption of some and 
ulceration of others. The ulcers within the nose were painted with a 
liniment of laudanum and oil, one part of the former and two of the 
latter. In June the ulcers were in process of healing, and their pro- 
gress was continued steadily. In July the tubercles on the face had- 
disappeared, but their remains might be detected under the skin, as a 
slight thickening of the tissues. To remove these remains, the iodide 
of mercury was successfully given in August; and, although the pri- 
mary effect of this remedy on the ulcers was not satisfactory, it no 
doubt contributed to their rapid healing, which took place immediately 
afterwards. The thickening and infiltration of the legs was attacked 
in May by cupping, the cupping being repeated in June, and received 
its coup de grace in August, from the eighteen days' course of iodide 
of mercury. The nocturnal pains in the legs and soles of the feet, 
disturbing sleep, complained of in June, yielded to the iodide of potas- 
sium, in doses of four, seven, to ten grains daily, assisted, firstly, by 
a general bleeding, and subsequently by the cupping practised for the 
swelling and infiltration of the integument of the legs. The iodide of 
potash was given in a peculiar manner, in one-grain doses every two 
hours. I have no experience of this mode of administering the remedy, 
and should have preferred five grains three times a day. This, how- 
ever, is a matter to be determined by experience alone. The arsenic 
seems to have played a very unimportant part in the treatment; it was 
taken in July for seven weeks, and increased too rapidly in dose, 
rising during that short period from five to fifteen drops of Fowler's 
solution. It had, therefore, every opportunity of developing its bad 
effects, without having time to work the benefit which arsenic is capa- 
ble of producing when given in moderate and long-continued doses. 
Early in June it was found necessary to stop it, from the occurrence 
of abdominal pains and cough. The insensibility of the feet and hands, 
which followed the pains in those parts, no doubt received benefit from 
the iodide of mercury, and also from the stimulating baths; but the 
remedy especially and most successfully directed against that symptom 
was bleeding and counter-irritation ; the patient was repeatedly cupped 
in the region of the spine, during the month of September, and had a 
large moxa applied in October; the ulcer made by the moxa was still 
open in December. 

The local treatment of the ulcers of elephantiasis is to be conducted 
according to the common principles of surgery, to allay inflammation, 



ELEPHANTIASIS. 365 

control decomposition, assist the separation of dead parts, and promote 
the healing process. The enumeration of these indications suggests 
the means and remedies which should he employed. Schilling recom- 
mends the tincture of aloes, myrrh, and amber, useful stimulants, 
which, in modern surgery, have been transferred to the stable, and 
given place to better means. He cautions us against the use of oils 
and fats, and strongly against mercurial ointments, which, he says, 
the skin cannot bear, so long as the morbid miasm retains its place 
within the body. 

It may be gathered from the views of treatment now put forth, that 
we must rely upon ourselves, and not upon any fortuitous gifts of 
Providence, to cure elephantiasis ; and on a due appreciation of this 
truth will, in great measure, depend our success, and the safety of 
our patient. We must use, and learn to use effectively, the means 
we have ; and in doing this, we shall acquire a more powerful specific 
than any that can be presented ready prepared to our hand. If, after 
this essay, the specific should arrive, we shall be the better able to use 
it judiciously ; if it should not be forthcoming, we have discovered 
the means of doing without it. It is probable that elephantiasis would 
never have been the scourge to the world it has, if this truth had been 
felt and acted upon earlier; if physicians had set themselves to dis- 
cover the cause of the disease, and followed up their search by work- 
ing methodically to remove that cause, rather than puzzle themselves 
and their successors by vain theories and equally vain experiments 
with the long list of simples which have been proved to be at least 
innocuous to man. Drs. Danielssen and Bb'eck, discarding all these 
empirical means, have determined the cause of the disease, be it miasm 
or poison, to be present in the blood. They have observed the altera- 
tions of the vital fluid occasioned by its presence ; they have traced 
the morbid effects of that cause in its action on the nervous system, 
and on the various tissues of the body ; they have pointed out that 
the morbid products are projected to the surface of the affected organs, 
and to the surface of the body ; and they have established a principle 
of treatment which shall change the composition of the blood, alter 
and improve nutrition, and eliminate the poisonous elements of the 
disease. In pursuing this principle they have the means to a favor- 
able issue in their hands, and I doubt not will successfully combat 
the disease which is now ravaging the shores of their country, and at 
the same time give a useful practical lesson to the world. 

The treatment of elephantiasis, therefore, whether it present the 
tubercular or anaesthetic form, should be conducted on the same prin- 
ciple. Portions of the blood of the patient should be taken from 
time to time, the quantity and frequency to be regulated by his 
strength ; and the blood so taken should be replaced by the nutritive 
matter derived from a well-selected diet. Thus, the morbid blood 
will give place to a sounder and more healthy fluid. Alteratives 
should be given, to alter and improve the chemistry of nutrition, 
than which none are better than arsenic, judiciously employed, and 
cod-liver oil. Thus, sanguification will be directly benefited, and 
with sanguification, as a matter of course, innervation. Elimination 



366 DISEASES FROM SPECIAL INTERNAL CAUSES. 

is to be rendered more energetic, to facilitate the requisite changes in 
nutrition. With tins view, the alimentary canal, the liver, the kid- 
neys, the skin, are all to be brought into more active play ; to which 
end, saline aperients and diluents are the appropriate remedies. 
Elimination, stimulation, and counter-irritation of that most potent 
emunctory, the skin, are all set in operation by baths, the hot air and 
vapor bath, sea-bath, sulphuretted bath, and caustic bath, already 
mentioned; and, for a local purpose, the skin may be further stimu- 
lated by counter-irritants, and by the use of the moxa. Local symp- 
toms, such as infiltration and thickening of the skin, require simply 
a local application of the same general principle, such as cupping or 
leeches; and the loss of sensibility of parts of the body, cupping and 
moxa to the corresponding parts of the spine. 

Having now discussed the general principles of treatment, as founded 
on the observations and researches of Drs. Danielssen and Boeck, it 
will be well to pass in review certain specific remedies at present in 
use in those countries where tubercular leprosy still prevails. The 
most important of these remedies are, the Asclepias gigantea, of Hin- 
dostan, and the Hydrocotyle Asiatica. 

The Asclepias gigantea, or Rumex gigantea, in the native language 
of Hindostan called Mudar, Muddar, or Mudarrh, has gained much 
reputation in the treatment of tubercular leprosy. Robinson, in his 
Essay on "Elephantiasis, as it appears in Hindostan," 1 remarks, that 
in the treatment of this disease, bleeding, mercury, and antimony, 
used singly, are of no use ; but that the last two, combined with the 
root of the mudar, have been found successful, when aided by the 
application of topical stimulants. The formula he proposes is com- 
posed of half a grain of calomel, three grains of antimonial powder, 
and from six to ten grains of the powder of the root bark of the ascle- 
pias, to be administered three times a day ; and the local stimulant, a 
weak acid solution (four grains to the pint, with ten minims of hydro- 
chloric acid) of the bichloride of mercury, applied with friction to the 
local affection. 

The Asclepias gigantea was discovered by Playfair, who called it 
vegetable mercury, and regarded it as specific in the cure of lues 
venerea, elephantiasis, and cutaneous eruptions. It is, he remarks, 
the most powerful alterative hitherto known, and an excellent deob- 
struent. In the jugaru, or leprosy of the joints, he never found it 
fail in healing the ulcers, and often succeeded in effecting a perfect 
cure of the disease. Robinson agrees with Playfair as to the utility 
of the asclepias in elephantiasis, and bears witness to its '"powerful 
effects as a deobstruent and sudorific, in almost all cutaneous erup- 
tions arising from obstructed perspiration and an apathy of the 
extreme vessels. Its action is quick and decided, causing a sense of 
heat in the stomach, which rapidly pervades every part of the 
system, and produces a titillating feel on the skin, from the renewed 
circulation through the minute vessels. It does not appear to be 
useful, or, indeed, admissible, where the affection is inflammatory or 

• " Medico-Chirurgical Transactions," vol. x. 1819. 



ELEPHANTIASIS. 367 

the eruption pustular. The great and rapid determination it causes 
to the skin has an obvious tendency to increase such diseases. I 
have tried it freely in lues venerea, but cannot venture to recommend 
it as a substitute for mercury. It will enable you to heal a chancre, 
but does not eradicate the poison. In the secondary symptoms, 
however, it is an admirable ally, superseding, by its certain efficacy, 
the exhibition of mezereon, sarsaparilla, and other vegetables of 
doubtful utility. Where mercury has been used, but cannot be 
pushed safely any further, the mudar rapidly recruits the constitution, 
heals the ulcers, removes the blotches from the skin, and perfects the 
cure. The only part of the plant useful in medicine is the bark of 
the roots. It should be gathered in the months of March, April, and 
May. The bark stripped from the root, being well dried, is readily 
beaten into a fine powder, of which the dose is from three to ten 
grains, thrice a day, for an adult ; six grains is enough to commence 
with. As the plant grows wild everywhere throughout Hindostan, 
it may be applied advantageously externally. I have often used a 
poultice made of equal parts of this powder and linseed dust, with 
decided benefit, in bad ulcers, from whatever cause ; and even in 
gangrene it acts as a detergent in cleansing the sore, and powerfully 
stimulates the healthy granulations. Decoctions may often be em- 
ployed, where the stomach would reject it in substance. When it 
causes pain in the stomach, a few grains of magnesia or prepared 
kali added to each dose will prevent that eifect. That this medicine 
is really the principal in the cure, I have no doubt ; for I scarcely 
ever succeeded by any means in curing or even checking the disease 
before I employed it, and have scarcely ever failed of doing both 
since." 

The asclepias has been employed in combination with arsenic, as in 
the celebrated " Asiatic pills," the formula of which is as follows : 

Arsenici protoxydi, gr. lv. 

Piperis nigri, ^ix. 

Asclepiadis giganteee, radicis corticis, s;iv. ^iv. 

The arsenic and black pepper are to be well rubbed together, at 
intervals of time, for four days ; the mudar and water are then added, 
to form a mass, and the latter is to be divided into eight hundred pills. 
The dose of these pills is one twice a day, each pill containing one- 
fourteenth of a grain of arsenic. 

The mudar powder is also used in Hindostan in the form of an oint- 
ment, in combination with lard or spermaceti cerate. 

The other vegetable remedy which has attained so high and appa- 
rently so deserved a reputation in the East, the Hydrocotyle Asiatica, 
is a plant resembling in appearance and ordinary characters the 
common hydrocotyle of the stagnant ponds of this country. The 
hydrocotyle asiatica is reputed to be specific in many diseases, par- 
ticularly those of the skin, and useful in all cases of leprosy. Mr. 
Hunter, in his report to the Board of Health of Madras, in February, 
1854, on fifty cases of disease of various kinds, of which thirty were 
cured, and the rest greatly benefited, remarks, that " the affections 
in which this medicine has been peculiarly efficacious are, ulceration, 



368 DISEASES FROM SPECIAL INTERNAL CAUSES. 

syphilis, and scrofula. Almost all cases of ulceration are cured with 
this remedy. Amongst the cures were several cases which had 
resisted other modes of treatment. This medicine may be recom- 
mended as an excellent stomachic and tonic. It appears to have 
a peculiar action on the capillaries of the mucous surfaces, and on the 
skin ; it causes at first a sensation of heat in the stomach, and at the 
same time a prickling in the extremities and then over the whole skin 
of the body, soon followed by an augmentation of appetite and trans- 
piration, and a general improvement in the health." 

M. Boileau, a physician of Mauritius, published an account of this 
plant, as a remedy for tubercular leprosy, in 1852 ; and M. Jules 
Lepine, of Pondicherry, in the Journal de Pharmacie et de Chimie for 
1855, has given a further description of the plant, with a chemical 
analysis, pharmacology, and list of the formulae used in the Govern- 
ment dispensary at that place. The properties of the plant seem to 
be due to a peculiar vegetable principle which he names vellarine, 
from vellarai, a native name of the hydrocotyle. Vellarine is a thick, 
pale yellow oil, having a bitter and penetrating taste which abides for 
some time on the tongue, and is most abundant in the roots, wherein 
it exists in the proportion of somewhat more than one per cent. 
Besides the vellarine there is a yellow oil, brown resin, green resin, 
saccharine extract, non-saccharine extract, and bitter extract ; the 
latter, in the proportion of ten and a half per cent., is found only in 
the root. The fresh plant is slightly bitter and aromatic in taste. 

The pharmaceutical preparations of the hydrocotyle are a powder 
of the entire plant, of which the dose ranges from one to six grains 
daily; a syrup, prepared from the juice, useful for children, the dose 
ranging from two drachms to two ounces daily ; a tincture, the daily 
dose ranging from ten to forty drops ; an infusion ; an ointment of the 
green plant ; and baths, containing four pounds of the plant, either 
green or dried. Similar preparations are made from the root, and 
are much more active than those of the entire plant, the root con- 
taining, as already mentioned, the largest proportion of vellarine. 
Vellarine cannot, however, be employed separately, from its great 
hygrometric qualities and active tendency to decompose. Vellarine 
has also the property of volatilization at 212°, and the virtues of the 
plant are consequently destroyed by exposure to heat. For this 
reason decoction and extract are inadmissible forms. 

Dr. Marshall, of Bombay, found nitric acid a valuable and successful 
remedy, exhibited in the dose of one drachm daily, diluted with a 
pint or a pint and a half of water. Of two hundred patients treated 
on this plan, more than one-third were cured, and the greater propor- 
tion of the remainder much benefited. 

EXISTING FORMS OF ELEPHANTIASIS. 

Taking a mental survey of that grand, that elephant disease, the 
leprosy of the middle ages, which forms so prominent a feature in 
the history of Europe, and especially of Great Britain, of which 
examples have not very long vanished from our land, the question 



ELEPHANTIASIS. 369 

naturally arises to the mind, And is it gone ? And if it be gone, 
has it left no remains behind ? Are there no traces of the leprosy ? 
Is there nothing at the present hour which belongs to, is a part of, 
is a living record of that immense disease ? Can our medical * 
antiquaries discover no impression of its gigantic footsteps ? Has it 
passed away like a shadow, or like the wind totally, and never to be 
seen again ? To which we answer, It would be contrary to all 
analogy to suppose that it had so totally passed away as not to leave 
a trace ; and yet no sign exists in the records of medicine to tell us 
that such is not the case. But though the sign may be absent in the 
records of medicine, the infallible sign remains imprinted on man. 
Leprosy exists amongst us still, but only as a faint trace of a worn- 
out disease, or as an ember of the burnt-out fire. God forbid that the 
spark should be rekindled ! I repeat, that elephantiasis still exists 
amongst us in this country as a faint trace of its former self, and the 
observation of that trace, however faint, becomes a matter of inter- 
esting research. Although a mere shadow in comparison with the 
parent disease, it is nevertheless sufficient to occasion considerable 
annoyance to the sufferer, and to bring him not unfrequently under 
the inspection of the medical man. Nor, when once pointed out, can 
the medical man doubt for an instant the nature of the disease which 
he has before him : there is the insensibility, the deposition, the 
blanching, the exhaustion of function, and the atrophy of the parent 
malady, with all their original distinctness, indeed, one complete 
symptom of the pure elephantiasis, preserved unchanged, as it existed 
amongst the Jews, and as it is to be found at this moment on the 
shores of Norway, the symptom which was called by the ancients 
morphoea. This symptom, or rather sign, has been handed down to 
us by our forefathers, and it is this which I shall now proceed to 
describe, preserving the name by which it was originally known, 
namely, 

MORPHCEA. 

Morphoea, derived from the Greek word nop<pr n forma, signifying a 
visible appearance, and in application to its seat, a visible appearance 
or spot upon the skin, is, as its name implies, a spot upon or in the 
skin, of irregular form, and either white, morplioza alba, or of a dark- 
brownish or blackish hue, morphoea nigra. Moreover, morphoea alba 
admits of a secondary division, from presenting two varieties, one in 
which there is induration of the skin, from deposition in its tissue of 
a lard-like substance, morphoea alba lardacea, vel tuberosa ; the other 
being distinguished by atrophy of the skin, and by a greater degree 
of insensibility, morphoea alba atrophica, vel ancesthetica. 

MORPHCEA ALBA LARDACEA. 

Morphoea alba lardacea, vel tuberosa, presents itself in the form of 
one oi- several circumscribed patches, varying in size from a crown-piece 
to several inches in extent, and may occur on any part of the skin. 
The surface of the patch is uniform with the cutaneous integument, 
being neither elevated nor depressed, but remarkable for its marble- 

24 



370 DISEASES FROM SPECIAL INTERNAL CAUSES. 

like whiteness, smoothness, and polish. It is more or less dense and 
hard, and frequently roughened on the surface by a slight desquama- 
tion of dried-up cuticle. Its hardness and density serve to isolate it 
from the surrounding skin as completely as its color, and when it 
occurs in small patches, it has the appearance of being inlaid in the 
skin. When recent, the edge of normal skin immediately surrounding 
it presents a delicate lilac blush; but in cases of long standing no such 
border exists. 

The smoothness, whiteness, and polish of the morbid skin, all proceed 
from the same cause, namely, infiltration into the tissue of the skin, or 
deposition within its cells, of a white, semiopaque substance, very much 
resembling lard. The skin looks as if it were injected with lard, and 
so distended as to obliterate the usual markings of the cuticle ; the 
wrinkles of the surface, if any exist, being produced by the folding of 
the skin during the motions of the body. Another cause of the white- 
ness of the skin, is the absence of the capillary plexus, and the almost 
total absence of bloodvessels. Sometimes' if the patch be large, a 
small vein may be seen gathering its tributary venules here and there, 
and sinking into the deeper structure, but the smaller patches look as 
if the skin were dead. Indeed, the deadness is not confined to appear- 
ance alone; the patches are more or less deficient in, and sometimes 
entirely devoid of, sensation, showing that not only the bloodvessels 
have become obliterated, but the nerves themselves are destroyed. 
In addition to these characters the patches have a peculiar baldness of 
appearance ; they are either devoid of the usual downy hair of the 
skin, or the hairs are bleached and imperceptible, and with the absence 
of hair formation, there is also an absence of the secreting function of 
the skin. 

The white patch of morphoea is often in a state now described, 
when first observed by the patient, but it always begins as an erythe- 
matous spot. When seen from the beginning, the spot is of small size, 
not larger than a fleabite, but in a few days it increases to the dimen- 
sions of a crown-piece or the palm of the hand. The redness is alto- 
gether unlike that of common erythema; it is never vivid, and scarcely 
exceeds a delicate lilac blush. The redness continues for some d;iys 
or weeks, and then without any other perceptible change, the skin 
corresponding with the lilac blush becomes blanched, and constitutes 
the kind of patch just described. The blanching process begins in the 
centre of the patch, and the redness then forms an areola around it, 
the areola being gradually narrowed until it becomes a mere border 
or rim, generally slightly raised, and at last fades away altogether. 
The development of the erythematous spot is usually accompanied 
with a feeling of tingling, like that occasioned by a pressure on a nerve. 
Sometimes this sensation is sufficiently powerful to attract the atten- 
tion of the patient, and give him annoyance; at other times it is 
scarcely appreciable. 

The size and number of the patches is very various. I have seen a 
number clustered together about the neck, each no larger than a lentil. 
A common and usual size is that of a crown-piece or the palm of the 
hand ; and I have seen one patch occupy the greater part of the thigh. 



ELEPHANTIASIS. 371 

The limb had the appearance of a piece of beautiful marble sculpture, 
highly polished. One felt tempted to touch it, it looked so white and 
smooth, to be convinced that it was not marble ; and one was astonished 
to find that though so lifeles in appearance, or resembling only living 
marble it gave the sensation of warmth. I recollect expressing my 
astonishment in looking upon that limb ; and, upon asking some ques- 
tion, the gentleman smiled, and said that it gave him no inconveni- 
ence, and if it were not for the appearance, he should not know that 
it was there. The patches rarely exceed three or four in number ; 
they are more frequent in women than in men ; and their common 
seat is the superclavicular region of the neck, the chest just below the 
mammae, the front of the abdomen, and the thighs. I have a patient now 
under treatment who had a patch on the forehead and nose, in which 
the morbid skin became shrunk and atrophied, and resembled a piece 
of dried white leather, perforated with small holes as if worm-eaten, 
and equally insensible. 

My friend Mr. Samuel Wood, of Shrewsbury, writing to me lately, 
says : " I have under my care, in the Infirmary, a woman aged thirty, 
suffering under a peculiar cutaneous disease. Under each mamma, the 
skin has deposited in it a sort of wax-looking secretion. The part bears 
a strong resemblance to a recently blistered surface on a dead body, only 
the cuticle remains, and there are minute bloodvessels ramifying over 
several parts. The edge is slightly raised, and beyond this there is a 
slight blush. The size of the patch on the left side is four inches long 
by three broad. It has been slowly progressing for about twelve 
months. There is little pain, but an occasional burning heat." 

Mr. C. Wilson Steel, of Lewisham, writing to me about the same 
time as Mr. Samuel Wood, says : " My patient is about thirty-five 
years of age, and has three children, the youngest being eight years 
old. She is of spare habit, active, has a soft, cool, but dry skin, rarely 
perspires, and enjoys good health. About seven years ago she per- 
ceived for the first time, a white spot on the back of the hand ; subse- 
quently, other spots appeared on different parts of the body, as on the 
abdomen, thighs, arms, &c. ; indeed, they -are dispersed more or less 
abundantly over the entire surface. The face is free, with the excep- 
tion of a stripe along and underneath the lower lip. The whiteness 
is more apparent in contrast with the color of the rest of the skin in 
summer than in winter ; and a new spot is preceded by a feeling of 
numbness and heaviness, which gives the patient warning of its occur- 
rence. The spots do not attain any magnitude ; and the spread of the dis- 
ease, takes place by new spots, which, when once formed, are permanent. 
They are distinguished from the surrounding skin, not by any raised 
margin, by any chap, ulceration, scurfiness, or other morbid condition 
visible to the eye; but simply by a dead pearl-like whiteness, bordered by 
an abrupt line, and exhibiting no transition, either on the side of the 
morbid or healthy skin. The spots are of various shape and size, and 
unaccompanied by sensation or pain, other than the premonitory numb- 
ness and heaviness already mentioned. In the winter the distinction 
between the white patches and the surrounding skin is not strikingly 
appreciable; but in the summer it is very evident." 



372 DISEASES FROM SPECIAL INTERNAL CAUSES. 

In this country, at the present time, the disease, perhaps, never 
advances beyond the state of skin now described ; it may become more 
extensive, harder, and more callous ; but my experience does not enable 
me to say whether any other symptoms of elephantiasis follow upon 
this first step. I have observed several cases of morphoea alba lardacea 
for periods varying between two and ten years, and have seen no 
other symptoms arise. But in countries where elephantiasis still exists, 
particularly in hot climates, this form of morphoea is often the imme- 
diate forerunner of that serious disease. 



MORPHCEA ALBA ATROPHICA. 

Morphoea alba atrophica, vel ansesthetica, diifers from morphoea 
lardacea not so much in degree of insensibility of the skin, as in the 
total atrophy by which it is attended. The patches are of the same 
figure and size, the skin as white, the lilac erythematous blush and the 
tingling sensation which precede, and the lilac border which surrounds 
them, the same ; but there is no deposition of morbid matter in the 
texture of the derma, and consequently no marble-like smoothness, 
polish, and hardness ; the lardaceous deposit is absent. In fact, the 
two forms of morphoea alba bear the same relation to each other as do 
the two forms of elephantiasis ; morphoea lardacea belonging to the 
tuberculated, and morphoea atrophica to the anaesthetic form. From 
the absence of deposition in the tissue of the derma, and, as a conse- 
quence of defective nutrition, resulting from deficient innervation and 
circulation, the skin is thinner than natural, sometimes remarkably 
attenuated, and sunk below the level of the surrounding integument. 
Its glandular apparatus participates in the atrophy ; there is neither 
sebaceous nor perspiratory secretion, and the part becomes bald from 
loss of hair. With this exception, the surface of the skin is unchanged ; 
the linear markings are perfectly regular, but smaller than natural, 
and before the tint of color reaches the dead white of complete insen- 
sibility and atrophy, the patch has merely the appearance of being 
delicately fair and soft, like that of an infant, contrasting strangely 
with the often brown and olive skin which surrounds it. 

Just as elephantiasis anaesthetica and elephantiasis tuberculata, being 
merely varieties of the same disease, may coexist, so morphoea alba 
atrophica may be present with morphoea alba lardacea, and sometimes 
the anaesthetic form precedes the deposition which subsequently takes 
place, and becomes a stage of the lardaceous variety. This is the case 
in a lady now under my care, who has six or eight patches of mor- 
phoea alba on the front of the body. Three of these, of longer standing 
than the rest, are distinctly lardaceous ; one is dense and hard only 
in the centre of the white patch, the skin around it being natural in 
texture, and simply blanched ; while several of the more recent patches 
are thin, soft, and white, and delicately fair in comparison with the 
tawny skin in which they are, as it -were, inlaid. 

Morphoea alba atrophica occurs for the most part on the front of 
the trunk of the body, particularly wherever the integument is thin, 
as beneath the mammae, at the root of the neck, in the groins, and on 



ELEPHANTIASIS. . 373 

the inner side of the arms and legs. Three or four times I have seen 
it on the forehead, where it resulted obviously from paralysis of a 
branch of the supra-orbital nerve. It existed as a groove, about half 
an inch in width, in the direction of that nerve ; the skin was white, 
shrunken, and insensible, the borders of the affected track being 
slightly raised, and of a lilac tint. In an advanced stage of the dis- 
ease, the skin sometimes becomes shrivelled and dried up, like parch- 
ment ; this is more particularly the case over a hard surface, as upon 
the head. 

The following is an example of morphoea alba of the forehead occur- 
ring over the supra-orbital nerve, presenting itself in the first instance 
in the simple anaesthetic form, and subsequently taking on, in part, 
the lardaceous character. The patient first came before me in the 
winter of 1851, being then nineteen years of age, and stated that the 
disease had existed for two years. He first observed it after a fit of 
excitement, when the whole face was flushed, and contrasting with 
this flush there was a streak of white on the forehead, like the wheal 
of nettlerash or that produced by a whip, only that it was not raised. 
The streak began at the inner end of the left eyebrow, and ran up- 
wards to the margin of the hair. After a short time he perceived that 
the white streak had become permanent ; and still later, that a small 
circular bald spot of area (alopecia areata) had formed on the summit 
of the head, to the left of the middle line, and at some distance from 
the end of the streak. 

In March, 1855, he consulted me for the second time ; the white 
streak had now become a nearly straight white band, about three- 
quarters of an inch in breadth, extending from the inner end of the 
eyebrow to the summit of the head, and there joining with the original 
spot of area, now considerably increased in size. On the forehead the 
central part of the band was raised to the level of the adjacent skin, 
by the deposition in its structure of the peculiar lardaceous substance 
of tubercular elephantiasis. This deposit rendered the surface smooth 
and polished, obliterating the linear markings of the skin, and destroy- 
ing its natural texture. And in place of the normal mottled redness 
produced by the capillary vessels, there was a coarse plexus of minute 
venules, the trunks of which dipped from point to point into the small 
spaces between the lobules of the morbid deposit. This venous plexus 
was not evenly distributed over the whole of the raised portion of the 
diseased skin, but was chiefly conspicuous in the central part, where 
it existed in small patches, and gave a reddish tint to the centre of 
the white. On either side of the elevated portion of the band, the 
morbid skin subsided below the level of the adjoining integument, 
and presented the characters of the atrophic form of the disease, pale, 
thin, and atrophied ; no vessels whatever being perceptible in its 
•structure. Beyond this groove, the surface gradually rose, and merged 
into the healthy integument, and the border of the sound skin pre- 
sented the pale lilac elephantiasis blush which constitutes the ordinary 
limit of the patches of morphoea alba. We have thus brought under 
our eyes, as far as is possible in the living body, the actual process of 
the conversion of morphoea atrophica into morphoea tuberosa. Reach- 



374 DISEASES FROM SPECIAL INTERNAL CAUSES. 

ing the summit of the forehead, the broad white band meandered 
through the hairy scalp to the top of the head, following the course 
of the supra-orbital nerve, and, where that nerve ends, terminated in 
a round patch of alopecia areata (morphoea alopeciata). The gently 
undulating course of this broad band suggested to the mind the idea 
of a river as represented on a map, flowing to the sea, or the flexuous 
progression of a serpent : hence, probably, the origin of the term 
ophiasis or tyria, applied by the ancients to this form of alopecia. 
The whole extent of the disease on the scalp presented the form of 
morphoea atrophica ; the integument along the centre of the band and 
on the patch of area was so thin, that the finger seemed to touch the 
bone, and was perfectly bald, from the ansemic and atrophic condition 
of the skin. Along the sides of the band the integument rose to the 
level of the rest of the scalp, and was furnished with a few stinted, 
bent, and twisted hairs. The atrophic part of the morbid skin was 
deficient of sensation, but the tuberous portion was less so, and, 
compared with my observations four years before, had recovered some 
of its sensibility. 

Besides the progress made by the chief patch of the disease upon 
the forehead and head, the patient called my attention, at his last 
visit, to a white, depressed spot, a few lines in diameter, which had 
appeared on the left side of the nose, a little below the inner angle 
of the eyelids ; and further, to a similar appearance on the ala of the 
nose, which looked like a cicatrix, and had occasioned atrophy of the 
part. This latter had given rise to some little deformity, and had 
excited in his mind a not unnatural alarm for the safety of his nose. 

I have mentioned that the disease appeared originally without any 
symptoms to denote its invasion; and during the whole period of its 
existence it has been the unsightliness of the patch, and not any 
suffering occasioned by it, which caused him anxiety. Except when 
excited by business, or his digestive functions are disturbe'd, he is not 
aware of any sensation in the part; but when any disturbance of 
circulation takes place from the causes referred to, he experiences a 
" heavy dead pain" around the edges of the patch on the forehead, and 
a prickling pain around those of the scalp. 

On his visit to me in 1851 I prescribed for him iodide of potash in 
infusion of quassia, and the local application of the compound tincture 
of iodine. In 1852 he saw another surgeon, who called it " gangrene 
of the skin," and prescribed a gentle mercurial course, with the local 
application of a solution of the bichloride of mercury. In 1853 he 
was seen by Sir Benjamin Brodie, who advised him full doses of 
sarsaparilla, and local frictions with the strong citrine ointment. He 
does not appear to have given any of these means such a trial as could 
influence a disease so deeply rooted, nor to have given his adviser the 
opportunity of regulating or modifying the treatment from time to- 
time. In April, 1855, he returned to me, when I ordered him the 
cod-liver oil, half an ounce twice a day, and five minims of Fowler's 
solution of arsenic, with the same number of antimony wine three 
times a day, and local friction with tincture of aconite in combination 



ELEPHANTIASIS. 375 

with soap-liniment. As I have not seen him since, I am unable to re- 
port the success of this plan. 

MORPHCEA NIGRA. 

Morphoea nigra resembles in origin and general symptoms the two 
preceding forms, but differs from both in the conservation of the pig- 
ment-forming function of the skin, which is increased instead of being 
suspended, as in morphoea alba. The persistence of this function indi- 
cates a less degree of disorganization of the integument than in the two 
previous states ; there is no condensation and hardening of the skin ; 
and if there be thinning, it is present in a considerably less degree than 
in morphoea atrophica. The degree of insensibility is about the same 
or somewhat less than in the other kinds ; the patches are rarely sunk 
below the level of the integument, but sometimes are rendered promi- 
nent by oedema. Patches of morphoea nigra were present in all the 
cases of elephantiasis which have come under my observation, but I 
have not seen it independently of that disease ; sometimes the patches 
are round, and not larger than a crown-piece; at other times they may 
be as large as the palm of the hand ; in one instance the body was 
spotted all over with them. 

The tint of color in morphoea nigra presents some variety ; it is 
sometimes a brownish-yellow, sometimes brown, and sometimes so dark 
as to approach to a blackish hue. . The pigment does not seem to be 
confined to the surface of the derma, but extends into it for some depth, 
not only in the walls of the glandular apparatus of the skin, where it 
might be expected, but also in the interglandular portion. When any 
erythema is mingled with the discoloration, the patches have a purplish 
hue; the cuticle is for the most part smooth and shining, and some- 
times acquires an almost metallic brilliancy ; at other times it is rough- 
ened by desquamation. In early stages of the disease there is often 
an excess of sebaceous secretion united with the discoloration, which 
gives to the skin a greasy appearance, but later in the attack the 
patches are dry and devoid of secretion. 

MORPHCEA ALOPECIATA. 

Elephantiasis produces, as we have seen, a total disorganization and 
complete atrophy of the skin, and necessarily destroys the secreting 
functions of that organ ; the perspiratory, sebiparous, chromatogenic, 
and trichogenetic functions are suspended or arrested, and the glan- 
dular and formative apparatus of those functions is atrophied, and 
ultimately obliterated. On the general surface of the body the patches 
of morphoea are smooth and bald, or the hair covering them is color- 
less or white ; and when, as before related, the path of morphoea is 
situated on the head, the integument is greatly thinned, and the hair- 
follicles are destroyed. 

In the case of morphoea alba of the general surface of the skin, I 
have shown that the pathognomonic characters of the disease are such 
as to point directly to elephantiasis as their source, and to leave no 
doubt on the mind that morphoea is a relic of that bygone scourge of 



376 DISEASES FROM SPECIAL INTERNAL CAUSES. 

this country, the great leprosy ; and I also believe that another affec- 
tion, more common than morphoea of the body, namely, alopecia areata, 
is a morphoea of the scalp and hair-bearing skin ; in other words, a 
morphoea alopeciata, bearing the same relation to elephantiasis as the 
morphoea already described. 

The specific characters of alopecia areata, or, as I shall henceforth 
call it, morphoea alopeciata, are, loss of hair in a patch of circular, 
and sometimes, when taking the course of a nerve, of lengthened form 
(ophiasis, tyria) ; loss of sensation ; loss of color, from arrested chro- 
matogenesis and diminished circulation of blood; and thinning of the 
skin, more conspicuous at the centre than at the border of the patch, 
sometimes approaching to a real atrophy. The surface of the affected 
patch is smooth, from a greater or less degree of obliteration of the 
papillary structure of the derma, from shrinking of the follicles conse- 
quent upon arrest of their function, and from absence or diminished 
force of the linear markings of the skin ; and it is less sensitive than 
natural, or totally insensible, from altered nervous function, probably 
a consequence of morbid alteration of structure of the nervous fibrils 
supplying the affected spot of the skin. 

Morphoea alopeciata is apt to occur at all ages, and in all ranks of 
life, but is more common in young persons than in the adult. It is 
sometimes permanent, more frequently transient, but always tedious, 
lasting sometimes for months, and sometimes for years. When the 
hair returns it may assume all the qualities of healthy hair, or remain 
short, white, and impoverished. It appears usually in the form of one 
or more circular patches, from which the hair falls off at once and 
suddenly, leaving a bald spot of considerable size. Sometimes, how- 
ever, its origin is small, consisting in the fall of a few hairs only, and 
it then increases more or less quickly by the circumference. At other 
times the loss of hair extends to the entire head, and involves, besides, 
the eyebrows and eyelashes. These latter cases are usually inveterate, 
though I have seen the hair return in several instances. But setting 
aside all these varied appearances, the one the most characteristic of 
the leprous disease, is that in which the spot is of inconsiderable size, 
the skin white, thin, smooth, and polished, as though stretched by 
shrinking, and devoid of sensibility and every trace of hair, the very 
follicles appearing to be obliterated. 

In children and young persons we are apt, and with a semblance of 
reason, to refer this state of the skin to defective nutrition : and it no 
doubt does result from defective nutrition ; but a defective nutrition 
originating in defective innervation, and the latter in the materies 
morbi of leprosy. In the adult this explanation is more obvious, 
since the period of active nutrition is over, and the insensibility of 
the skin points more directly to a local disorder of a nerve. A com- 
mon seat of the morphoea in the adult is the chin, where the bald, white, 
circular spot contrasts strongly in color with the hair-bearing skin, and 
is peculiarly obnoxious to the sufferer. 

It not uncommonly happens, that this local deficiency of action in a 
part of the skin is associated with general want of tone in the whole 
system, and the treatment demanded will call for the use of alteratives 



ELEPHANTIASIS. 377 

and tonics. At other times I have seen benefit result from the use of 
mild mercurials, in combination with the iodide of potassium, where a 
syphilitic affection had to be controlled ; but the special treatment for 
morphoea alopeciata consists of arsenic employed as a cutaneous 
stimulant and tonic, and local stimulants, such as acetum, cantharidis, 
compound tincture of iodine, liquor ammonise, solution of bichloride 
of mercury, &c. For morphoea alopeciata of the scalp, plentiful fric- 
tion with the hair-brush, in addition to the stimulants already 
enumerated, is indicated, together with the use of a stimulating 
wash or pomatum. Where the scalp is denuded to a great extent, 
advantage is often gained by dipping the head in cold water, and ex- 
citing the skin afterwards by friction with a towel. In a few cases 
this state of the skin has been attended with general emaciation, quick 
pulse, and irritable temperament, when I have had recourse to cod- 
liver oil, in addition to the preceding local and alterative treatment. 
In general, the skin becomes restored to its natural appearance, and 
the hair returns, although the curative change is always slow and 
tedious ; but occasionally, neither time nor treatment appears to have 
any remedial power over the affected skin, and the baldness becomes 
established permanently. 

THE LEVITICAN CODE. 

In further illustration of the nature of the true leprosy, or elephan- 
tiasis, it will be interesting to peruse the Scriptural account of this 
disease, contained in the thirteenth chapter of Leviticus, so frequently 
referred to by medical writers. The following appears to me to be an 
exact and accurate interpretation of this important chapter, so far as 
it treats of the diagnosis of leprosy : 

1. And the Lord spake unto Moses and Aaron, saying, 

2. When a man shall have an eruption in the skin like the eruption 
of leprosy, be it a tubercle, a scab, or a glossy spot ; then he shall be 
brought unto the priest : 

3. And the priest shall examine the eruption, and if the hair grow- 
ing on the infected skin be changed in its color to white, and if the 
morbid alteration in the skin sink deeply into it, and appear to involve 
the entire thickness of the skin; then the case is one of leprosy, and 
the disease is contagious. 

4. If the glossy spot be white, and affect only the surface of the 
skin, and the hair be not changed in color to white, then the priest 
shall seclude the patient for seven days ; 

5. And on the seventh day, if the spot remain as it was, and have 
not increased in extent, then the priest shall seclude him for seven 
days more ; 

6. And on the completion of another seven days, if the spot be 
somewhat dark, and have not spread, the priest shall pronounce the 
patient free from contagion ; the case is one of simple scab. 

7. But if the scab increase in size and spread, after he has been dis- 
missed by the priest as free from contagion, he shall be again admitted 
to examination. 



1 

378 DISEASES FROM SPECIAL INTERNAL CAUSES. 

8. And if the priest find that the scab is still spreading, then he 
shall pronounce the case to be one of leprosy, and contagious. 

9. When a man is affected with leprosy, he shall be brought to the 
priest ; 

10. And the priest shall examine him, and if he find the affected 
skin to be white and raised, and if the hair growing upon it be 
changed to white, and if there be an open sore [raw flesh] in the 
affected skin ; 

11. It is an old leprosy and contagious. 

12. And if a leprosy invade the whole body from the head to the 
feet; 

13. Then the priest shall consider, and even although the leprosy 
cover the whole skin, yet if it be all turned white [lepra vulgaris] he 
shall pronounce the patient free from contagion: 

14. But if there be an open sore, then there is contagion ; 

15. For the open sore is a proof of contagion, and the case is a 
leprosy. 

16. Or if the sore heal, and the skin become white, the patient shall 
come to the priest ; 

17. And if the priest be satisfied that the sore has healed and the 
skin is white, then he shall pronounce the patient free from contagion. 

18. Even in the case of a common boil which is healed ; 

19. If there be a white tubercle, or a glossy spot, white or reddish 
in color ; 

20. And the priest find the whole depth of the skin to be involved 
in the disease, and the hair to be turned white, it is contagious, a 
leprosy broken out of the boil ; 

21. But if there be no white hairs, if it be quite superficial, and 
somewhat dark in color, then the priest shall seclude the patient for 
seven days ; 

22. And if it spread extensively in the skin, the priest shall pro- 
nounce it a contagious eruption. 

23. But if the glossy spot remain, and spread not, it is a carbuncle, 
and the priest shall pronounce it not contagious. 

24. Or, if in the inflamed patch of skin there be an open sore, and 
in the sore there be a glossy spot, either reddish or white, 

25. And if the hair on the glossy spot be turned white, and the 
disease involve the entire depth of the skin, it is a leprosy broken out 
of the carbuncle; wherefore, the priest shall pronounce it contagious. 

26. But if there be no white hair on the glossy spot, and it be not 
depressed below the level of the adjacent skin, but be somewhat dark 
in color, then the priest shall seclude him seven days. 

27. And if on the seventh day it be spread to a considerable extent, 
then the priest shall pronounce it contagious ; it is leprosy. 

28. But if the glossy spot be stationary, and spread not, but be 
somewhat dark in color, it is an inflamed swelling of the carbuncle, 
and not contagious. 

29. If a man or woman have an eruption on the head ; or a man, on 
the hairy part of his face ; 

30. The priest shall examine it, and if he find that the disease sink 



ELEPHANTIASIS. 379 

deeply into the skin, and the hair growing from it be yellow and thin, 
he shall pronounce the disease to be contagious, it is a dry scall, even 
a leprosy of the head or beard. 

31. If, however, it be no deeper than the surface of the skin, and it 
be without hair, then the patient that hath the scall shall be secluded 
seven days : 

32. And on the seventh day, if the scall be not. spread, and if there 
be in it no yellow hair, and it affect only the surface of the skin, 

33. The patient shall be shaven, but the scall shall not be shaven, 
and he shall be secluded another seven days : 

34. And on the seventh day, if the scall be not spread, nor be deeper 
than the visible surface of the skin, then the priest. shall pronounce 
the patient to be free from contagion: 

35. But if after this the scall spread, 

36. The priest shall examine him again, and if he -find that the 
scall has really spread, he need not seek for yellow hair, the disease is 
contagious : 

37. But if the scall continue stationary, and black hair has grown 
up therein, it is healed, and no longer contagious. 

38. If a man or woman have in their skin glossy spots or white 
glossy spots, 

39. The priest shall examine them; and if the glossy spots be dark- 
ish white, it is a freckled spot, and not contagious. 

40. And a man may be bald, from the fall of his hair, without con- 
tagion. 

41. And a man may be bald on his forehead without contagion; 

42. But if there be on the bald head or bald forehead a white 
reddish sore, it is a leprosy : 

43. Then the priest shall examine it ; and if there be a white 
reddish tubercle like that which in leprosy appeareth on other parts 
of the skin, 

44. He is a leprous man, and the disease is contagious. 

Now the pathognomonic signs of leprosy, as described in this 
chapter, are : 1st, a glossy spot in the skin ; 2d, the disease pene- 
trating the entire thickness of the skin; and 3d, the hair growing 
from the affected skin being white or yellowish and faded ; to which 
may be added, as signs of an advanced stage of the disease ; 4th, a 
rising or tubercle of a whitish or reddish-white color, with or without 
fungous granulations (quick, raw flesh); and 5th, an ulcer (raw flesh). 
The favorable signs, on the other hand, are, spots of a dull white 
(lepra vulgaris), instead of glossy white, or glossy and dusky; the 
limitation of the disease to the visible surface of the skin; and the 
absence of any change in the hair. 

Judging from the language employed in verses 3, 4, 21, 25, 30, 31, 
32, 34, I am inclined to think that the Hebrews restricted the signifi- 
cation of the word " skin" to that part of the integument which at the 
present day we call cuticle; hence the distinction which is made 
between the visible surface of the skin, as in verse 4, and the entire 
thickness of the skin, the cutis or derma of modern writers, as in 



380 DISEASES FROM SPECIAL INTERNAL CAUSES. 

verse 3. The text of the two verses is as follows : Verse 4 : "If the 
bright spot be white in the skin of his flesh, and in sight be not deeper 
than the skin." Verse 3 : " And the plague in sight be deeper than the 
skin of his flesh." This distinction in reality constitutes one of the 
most important points of diagnosis between real leprosy and affections 
of the skin otherwise resembling leprosy ; while, on the other hand, 
I can see nothing, either in the expressions used, or in any part of the 
chapter, to lead to the inference that a subcutaneous disease is implied. 

In verses 20 and 21 some little difficulty is imported into the subject, 
by the apparent substitution of the word lower for deeper. Thus, if 
"in the place of the boil there be a white rising," and if " it be in sight 
lower than the skin;" but "if it be not lower than the skin," &c. It would 
seem by these words as if depression of the affected skin were implied, 
a condition distinct from depth, and having reference to the morbid 
alteration of the skin only in its effects as producing a disorganization 
and thinning of the skin, which actually does take place in elephan- 
tiasis ; but the context is opposed to this signification of the word. A 
"rising" cannot be said to be "lower" than the skin; whereas lower 
than the skin may mean deeper than the apparent surface. I should 
have thought it unnecessary to dwell on this variation of terms, but 
for the fact that in a subsequent verse the perplexity is increased, 
inasmuch as the word lower can have no other meaning than depressed. 
Verse 26: "But if the priest look on it, and behold there be no white 
hair in the bright spot, and it be no lower than the other skin, but be 
somewhat dark, then the priest shall shut him up seven days." 

Another observation to be made in connection with the 13th 
chapter of Leviticus, is, that the term "plague" is used synonymously 
with eruption ; a plague of leprosy means simply an eruption of 
leprosy, while leprosy is employed as a generic term, and includes 
any spreading eruption, as well as the more malignant disease, ele- 
phantiasis or true leprosy. Thus, verse 8 : "If the priest see that 
behold the scab spreadeth in the skin, then the priest shall pronounce 
him unclean; it is a leprosy." Again, verses 12, 13: "And if a 
leprosy break out abroad in the skin, and the leprosy cover all the 
skin of him that hath the plague, from his head even to his foot, 
wheresoever the priest looketh, then the priest shall consider, and 
behold if the leprosy have covered all his flesh, he shall pronounce 
him clean that hath the plague; it is all turned white, he is clean." 
The disease here referred to is evidently the lepra vulgaris of the 
present day, the boak or bohak of the Hebrews and the Arabians, 
the alphos of the Greeks, a known non-contagious affection. 

If, in the next place, we inquire what are the forms of disease set 
down as varieties of contagious leprosy in the Levitical code, Ave shall 
find them to be ten in number, as follows : 

1. A glossy spot (verse 2. Berat. Heb.) penerating the whole 
thickness of the skin, and on which the hair is white, is a contagious 
leprosy (verse 3. Tsorat, Berat lebena. Heb.) 

2. A glossy spot, affecting the surface only of the skin, the hair 
remaining unchanged (verse 4; simple scab, verse 6), but spreading 
in the skin (verses 7, 8), is a contagious leprosy. 



ELEPHANTIASIS. 381 

3. A glossy spot, white and somewhat raised, having within it a 
fungous-looking sore, the hair being white, is an old contagious 
leprosy (verses 10, 11). 

4. A fungous-looking sore (verses 14, 15), occurring in a person 
affected with a white leprosy (boak) covering the whole body (verses 
12, 13), is a contagious leprosy. 

5. A white elevation, or a glossy white or reddish spot (verse 19), 
penetrating the entire thickness of the skin, on the site of a healed 
boil (verse 18), the hair of the affected skin being white (verse 20), is a 
contagious leprosy. 

6. A glossy spot, either reddish or white, and accompanied with 
white hair, occurring in the midst of a carbuncle in course of healing, 
and penetrating the entire depth of the skin, is a contagious leprosy 
(verses 24, 25). 

7. The same as variety 6, without white hair, not depressed, some- 
what dark in color, but spreading ( verses 26, 27), is a contagious 
leprosy. 

8. A spot on the head or beard, accompanied by yellow, thin hair, 
and affecting the entire thickness of the skin, is a "dry scall" (verse 
30), a contagious leprosy. 

9. A spot on the head or beard, perfectly, superficial, without 
change in the hair, but spreading (verse 36), is a contagious disease. 1 

10. A white, reddish, elevated sore, occurring in a bald person, 
and where the absence of hair excludes one feature of diagnosis, the 
reddish sore being like that which appears on any other part of the 
body in a leprous person (verses 42, 43, 44), is a contagious leprosy. 

In other words, and more summarily defined, the ten varieties of 
contagious leprosy of the Levitical code are: 

1. The Tsorat or Berat lebena, Heb. ; Beras bejas, Arab.; Lepra 
leuce, Gfr. ; Elephantiasis Grsecorum; the bright white leprosy, true 
leprosy. 

2. A spreading scab; probably an eczema. 

3. The Tsorat, with fungous sore. 

4. Fungous sore in conjunction with lepra vulgaris ; the latter being 
the Boak, Heb. ; Lepra alphos, Gfr. ; dull-white leprosy. 

5. White elevation, with other signs of Tsorat, issuing from the 
cicatrix of a boil. 

6. The Tsorat, issuing from a carbuncle. 

7. The dusky spreading Tsorat ; the Berat cecha, Heb. ; Lepra 
mclas, Gfr. ; dusky or nigrescent leprosy. 

8. A dry scall on the head or beard ; deep. 

9. A dry scall on the head or beard ; superficial, but spreading. 

10. A white, reddish, elevated sore on a bald person. A Tsorat, or 
Berat lebena. 

Now, of the ten varieties of disease here designated under the generic 
term leprosy, it would appear that only eight deserve to be considered 

1 It is worthy of remark, that the word disease is used in this place (verse 36) instead 
of leprosy, although there can be no doubt, from the context, beginning with verse 29, that 
the disease leprosy is intended. 



382 DISEASES FROM THE SYPHILITIC POISON. 

as the true leprosy or elephantiasis : namely, the first, which may he 
taken as presenting the specific type of the disease ; the third and 
fourth, which add the fungous sore to the specific type ; the fifth, being 
the specific type developed in the scar of a boil ; the sixth, the specific 
type arising in a carbuncle ; the seventh, a variety of the specific type 
distinguished by its dusky color; the eighth, a " dry scall,'' involving 
in morbid alteration the entire depth of the skin ; and the tenth, being 
the specific type occurring on the head of a bald person. The remain- 
ing two varieties are, the second, a spreading scab, probably an eczema ; 
and ninth, a "dry scall," affecting the skin only superficially, but 
exhibiting a tendency to spread. For the latter reason alone, namely,, 
their progressive increase, they are classed with a contagious disease, 
as demanding, although not contagious in themselves, seclusion from 
healthy persons. 



CHAPTER XIV. 

DISEASES ARISING FROM THE SYPHILITIC POISON. 

The diseases of the skin arising from the poison of syphilis or lues, 1 
are the syphilitic eruptions or syphilodermata. These eruptions are to 
be considered as the manifestation of an effort on the part of nature to 
excrete or expel the poison of the blood through the skin ; therefore, 
before entering upon their description, it may be desirable to glance 
at the phenomena of the syphilitic poison. 

It is a well-known law of animal poisons, that, being once intro- 
duced into the blood, they excite in that fluid an action which has 
for its object the production of a similar poison, and this process goes 
on until the blood becomes saturated or overcharged with the morbific 
principle. As soon as this latter condition occurs, an inflammatory 
movement is set up, which results in the ejection or elimination of the 
poison. 

This inflammatory movement, or syphilitic fever, is therefore a sign 
of the accumulation of the poison within the blood to such a degree 
as to disturb the healthy functions of the body, and is attended with 
symptoms which indicate derangement of the nervous, vascular, and 
digestive systems, and especially of those surfaces of the body through 
which it is possible for elimination to occur. 

The blood is charged with a poisonous principle, and all the organs 
and structures supplied with that blood suffer to a greater or less 
extent. The brain evinces its suffering by mental dejection; the 
nerves, by a general feeling of prostration and debility. Everything 
is couleur de plomb around the patient; he is unable to pursue his 
avocations with comfort, and if they require the exercise of his mind, 
scarcely at all. He is oppressed with a sense of impending evil. 
Besides the lassitude and languor which evince the poisoned condition 

1 Der. Lues, ab Mur, solvere, dissolvere. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 383 

of the nerves, there is often neuralgia to an intense degree, sometimes 
affecting the head or face, and sometimes the joints, when it goes by 
the name of rheumatism. The neuralgia presents the peculiarity of 
being nocturnal, that is, of being most severe during the night, and 
often, but not always, entirely absent by day. The pulse is quick- 
ened ; the tongue is coated, white, broad, and indented by the teeth. 
The fauces are more or less congested, the tonsils and soft palate being 
frequently swollen ; there is ' irritation of the larynx, producing a 
mucous cough, and often nausea. The bowels are sometimes consti- 
pated, sometimes relaxed ; the urine sometimes clear and limpid, at 
other times loaded with salts. The conjunctiva is congested and 
muddy, and the whole skin remarkable for its yellowish and dirty 
appearance, looking as if saturated with impure and discolored humors. 
Sometimes it is dry ; at others, suffused with a greasy secretion ; and 
at night, pours out an abundant and fetid perspiration. 

Such are the general symptoms of the syphilitic fever, or secondary 
syphilis, but they may not all be present, and those which exist may 
be complicated by local congestions of the mucous membranes. The 
symptoms which may be selected as pathognomonic of syphilitic fever 
are, mental and nervous depression and prostration ; congested fauces 
with sore throat ; congested and muddy conjunctiva ; congested and 
discolored skin, the congestion being partial or general, and assuming 
the form of an eruption ; and added to these, neuralgic pains. 

In this combination of symptoms, we are forcibly struck with the 
resemblance which they bear to those of the exanthematous fevers, 
measles, scarlatina, and small-pox. Firstly, the nervous depression, 
showing the stagnating influence of the accumulated poison. Secondly, 
the congestion of the mucous membrane, particularly of the fauces, 
showing the effort made by the bloodvessels to eject the poison 
through that tissue. And, thirdly, the cutaneous exanthema, which 
completes the triumph of the pressure from within, and is the sign 
that the poison is driven to the surface and is in process of expulsion. 

Even the irregular symptoms, the partial and local congestions, 
have their parallel among the exanthemata. Let me adduce one or 
two examples. A' printer, aged fifty, six weeks after suspicious 
connection, was exposed, in the winter season, to the dangerous effects 
of a heated and impure atmosphere during the day, and cold and 
rain at night. At this time he became the subject of nocturnal head- 
aches, attended with profuse fetid perspirations. One night, after 
more fatigue and exposure than usual, his headache was excessively 
severe, his breathing oppressed, he had intense pain in his chest, and 
seemed in danger of suffocation. These symptoms of pulmonary 
congestion, an effort on the part of nature to eliminate the syphilitic 
poison through the mucous membrane of the air-tubes, were relieved 
by a general eruption of roseola. 

A married lady had for two years been subject to a troublesome 
bronchitis, which the usual means had failed to cure. It came on at 
first in the form of periodical attacks, and was attended with serious 
dyspnoea. Latterly, the disease had become more constant and less 
severe. Her application to me arose from her having an eruption on 



384 DISEASES FROM THE SYPHILITIC POISON. 

the forehead, which I recognized as syphilitic. The eruption had 
appeared with the first attack of bronchitis, and in her own rnind, she 
connected the disorders together. It occurred to me also, that the two 
disorders might proceed from the same cause ; that the bronchitis, 
like the cutaneous eruption, might be maintained by the syphilitic 
poison. I treated this lady as I should have done an ordinary case 
of constitutional syphilis, and both affections got well together. 

Thus far for resemblances to the exanthematic fevers ; but there 
are also differences between the syphilitic fever and that of the 
exanthemata, so remarkable as to call for special consideration. 
The exanthematous fevers are more violent, more regular, and more 
transient than the syphilitic fever ; in other words, they are acute, 
while the syphilitic fever is chronic. It is true that instances of 
syphilitic fever often happen, which present all the symptoms of the 
most violent fever, and are attended with delirium; but such cases are 
the exception, and not the rule. 

The cause of the differences of character perceptible between the 
exanthematous and the syphilitic fever appears to me to be due to a 
radical difference in the nature of the poison. The poison of measles, 
scarlatina, and small-pox, probably originates in conditions extraneous 
to the animal body ; it reaches the blood as an element foreign to its 
nature, and as soon as it has accumulated to the saturating point, a 
violent effort is made for its expulsion. The expulsive effort obeys 
rigidly certain laws of order and time, and the poison being once re- 
moved, the blood of the patient may enjoy an immunity from a 
re-excitement of the same action for the rest of life. 

How different are the phenomena which characterize the poison of 
syphilis. The syphilitic poison originates in the human body ; it is 
probably little more than a modification of the natural secretions; it 
is consequently less irritant in its nature ; and it tends to assimilate 
with the blood and with the tissues, rather than to excite an action 
which may result in its removal. Hence the poison is slow in accumu- 
lating ; its excitation of febrile symptoms seems rather a matter of 
accident than the consequence of an irresistible law ; the patient enjoys 
no immunity from a recurrence of the morbid action ; and the poison 
is only partially removed by the febrile effort. 

There is another striking difference between the exanthematic and 
the syphilitic poison. In the former, a second febrile attack never 
follows from the same original infection. In the latter, a second, a 
third, and, indeed, an indefinite succession of outbursts of the poison 
is the common manifestation of its action. In the exanthematic fever, 
the blood and tissues of the body are so modified by the excitation 
they have undergone, that they are indisposed to take on again a 
similar action. The poison of syphilis having once entered the system, 
the blood and tissues appear to become accustomed to its presence ; it 
remains for years, or for life, and gives notice of its existence from 
time to time, by a variety of symptoms. Nay, more, it is transferable 
to offspring, not merely to one, but, as I believe, to an indefinite series 
of generations. 

I have said that the occurrence of syphilitic fever seems rather the 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 385 

effect of accident than the result of an immutable law. I mean, that 
the poison itself appears to be insufficient to light up the fever with- 
out the intervention of an accidental exciting cause, such as cold ; 
and the exciting cause frequently determines the shape which the sub- , 
sequent symptoms assume. Sometimes the leading feature of the fever 
is sore-throat, sometimes neuralgia or rheumatism, sometimes iritis, 
sometimes cutaneous eruption, and sometimes periosteal inflammation ; 
these differences of effect being partly clue to the nature of the exciting 
cause, and partly, also, to the constitution of the individual. 

One of the most striking of the phenomena of the syphilitic poison, 
is the modification or alteration which it undergoes in its manifesta- 
tions, under the mere influence of time. These modifications are ex- 
pressed in the terms primary, secondary, and tertiary. With the morbid 
phenomena appertaining to primary syphilis we have nothing to do 
at present ; as the syphilodermata all belong to secondary and tertiary 
syphilis, and principally to the former. Then the syphilitic poison 
undergoes another important modification, in consequence of being 
transmitted through the blood of the infected person, and being 
presented to a new person or to new blood, not in its crude shape, but 
as a modification. This latter phenomenon forms the basis of here- 
ditary and infantile syphilis. Hence the syphilodermata admit of a 
primary division into syphilodermata primitiva, or syphilitic eruptions 
proceeding from the first poison ; and syphilodermata hereditaria, or 
eruptions resulting from the communication of the poison to the 
foetus or infant. To these may possibly be added at some future 
period a class of syphilodermata mitigata, to include those modifications 
of syphilitic eruptions which are observed where the poison has passed 
through the blood of another, and is presented to a new person, in an 
assimilated condition, in the secretions of the infected individual. 

Then, taking syphilodermata as divisible into these principal heads, 
Ave have next to consider the eruptions of the first period, or those 
which correspond with the so-called secondary syphilis ; and the 
eruptions of the second period, or those of tertiary syphilis. In like 
manner, we have in syphilodermata hereditaria, a first, a second, and a 
third period. 

To render this classification of syphilitic eruptions more clear, I have 
arranged them in the form of a table, as follows : 

I. Syphilodermata Primitive. 

First Period — 

1. Syphiloderma erythematosum. 

Roseola syphilitica, 
Maculae syphiliticse. 

2. Syphiloderma papulosum. 

Lichen syphiliticus, 
Lichen pustulosus. 

3. Syphiloderma tuberculosum. 

Tubercula syphilitica, 
Tubercula ulcerantia. 
25 



386 diseases from the syphilitic poison. 

4. Syphiloderma pustulosum. 

Rupia syphilitica. 

5. Syphiloderma pilare. 

Alopecia syphilitica. 

6. Syphiloderma ungueale. 

Onychia syphilitica. 
Second Period — 

1. Syphiloderma erythematosus. 

Erythema (vel psoriasis) palmare et plantare, 
Lupus erythematosus. 

2. Syphiloderma tuberculosum. 

Tubercula mucosa, 
Tubercula ulcerantia, superficialia, 
Tubercula ulcerantia, profunda, 
Lupus ulcerosus, syphiliticus, 
Tubercula gummata. 

3. Syphiloderma ulcerans. 



II. Syphilodermata Hereditaria. 

First Period — 

1. Syphiloderma erythematosum. 

Erythema syphiliticum infantile. 

Second Period — 

2. Syphiloderma tuberculosum. 

Lupus syphiliticus. 

Third Period — Lepra. 

SYPHILODERMATA PRIMITIVA. 

FIRST PERIOD. 

Secondary Syphilis. 

SYPHILODERMA ERYTHEMATOSUM. 

ROSEOLA SYPHILITICA. 

Roseola 1 is one of the simplest of the forms of constitutional syphilis, 
and presents the common characters of an exanthematous fever, usually 
of a mild kind, but sometimes severe. It is the form in which the 
general effort for the elimination of the syphilitic poison is manifested ; 
is indicative of a certain power on the part of the collected poison; 
and is the common precursor of the other forms of eruption. The 
period at which it makes its appearance is between six and nine weeks 
after the development of the primary disease. 

Like measles, which it closely resembles, it begins with general 
febrile symptoms, prostration of strength, and congestion of the mu- 
cous membrane of the fauces. Then follows the exanthem, which is 
spread more or less extensively over the surface of the body, being 
most perceptible on those parts which are covered by the clothes. 

1 Portraits of Diseases of the Skin, Plate XXIV., P. 



SYPHILODERMATA, Oil SYPHILITIC ERUPTIONS. 387 

The efflorescence remains apparent for a variable period, a few days or 
as many weeks ; it is brightest in the evening and under the influence 
of excitement, and is attended, on its decline, with exfoliation of the 
cuticle. Very commonly it leaves behind it a fawn-colored or brownish 
stain, and a dry and sordid state of the skin. 

Roseola syphilitica commonly presents itself in the form of unde- 
fined patches, giving to the skin an appearance which is best described 
by the term " mottled," roseola versicolor. The appearance is identical 
with that of common idiopathic roseola, or measles, and is due, like 
the two latter, to the manner of distribution of the bloodvessels in 
the skin. Perhaps the congested patch represents the ramifications 
of a single small arterial trunk ; perhaps it embraces that small capil- 
lary system which is normally emptied by a separate venous trunk ; 
perhaps, again, it includes the small district of skin, the circulation of 
which may be governed by the ultimate divisions of one small nervous 

twi £- 

Occasionally, the roseolous congestion is defined in its boundary, 
forming circular blotches, roseola orbicularis ; and when this is the case, 
it often exhibits a tendency to spread by the circumference, while it 
fades in the centre, and so gives rise to an annulate form of roseola, 
roseola annulata. This annulate spread of congestion of the skin is 
another peculiarity of that structure, which is universal, and which 
also depends, very probably, upon the distribution of nervous influ- 
ence. Syphilitic roseola, therefore, may present itself to our exami- 
nation under three varieties of form, namely, as a patchy and mottled 
redness, as circular blotches, and as congested rings. 

Besides the varieties which depend on differences of form, there are 
others which are due to degree of congestion of the skin. In some the 
redness of the blotches is uniform, or nearly so; others seem to deserve 
the appellation punctated, from the more vivid redness and greater 
congestion of the follicular plexus of capillaries, roseola punctata; and 
in a third case, the latter condition has progressed so far as to lift up 
the follicular pore, and produce an indistinct papule, roseola papulata. 
These differences, however, are mere differences in degree of conges- 
tion ; the same morbid action exerting itself with greater or less force, 
or operating against a structure of greater or less strength ; they are 
mere varieties of roseola, while roseola is only a variety or stage of 
the other forms of syphilitic eruption. 

When the congestion of syphilitic roseola subsides, it leaves behind 
it a more or less stained appearance of the skin, and this is a common 
character of all the syphilitic eruptions. The stain generally corres- 
ponds with the form of the eruption which preceded it, and is of a 
brown color of varying tint ; deep, and almost approaching to black 
in persona of dark complexion; of lighter hue, and verging to fawn, 
or a dead-leaflike tint, in the fair. Sepia, tinged with red or yellow, 
would, in the hands of the artist, produce all the variations of color 
which the syphilitic stain presents. Thesestains of the skin are termed 
macula? syphilitica'. Sometimes the roseolous congestion which pre- 
cedes theni is so slight that they appear to be independent of such an 
origin ; but this is not the case ; they are always the effect of a con- 



388 DISEASES FROM THE SYPHILITIC POISON. 

gestive action in the skin. Whether, therefore, the maculre syphili- 
ticae are primary in their appearance ; whether they are consecutive 
upon roseola, or consecutive upon other forms of syphiloderma, they 
may be classed under the head of erythematous congestions. One 
variety of macula? I have had occasion to distinguish from the rest, 
under the name of melanopathia syphilitica. 1 

Taking a general view of syphilitic eruptions, they will be found to 
present two principal forms ; the one being simply congestive, and 
unattended with elevation of the skin, the other presenting the obvious 
feature of elevation. To the non-elevated group belong roseola and 
macular syphilitica; to the elevated group the small pimples of 
lichen, and the larger pimples or tubercles of tubercular syphilis. 
These differences are, however, more apparent than real, and may be 
regarded as stages of development of the same disease. Roseola, by 
an easy gradation, is converted into lichen, or tubercular syphilis ; 
and these latter, by simple subsidence, become syphilitic maculse. 
Roseola papulata constitutes a link of transition between the non-ele- 
vated and the elevated form of the syphilodermata. 

SYPHILODERMA PAPULOSUM. 
LICHEN SYPHILITICUS. 

When the eruptive force is sufficiently powerful to elevate the 
pores into distinct pimples, the case is one of lichen. It is no uncom- 
mon thing to find the mottled roseolous rash forming a base upon 
which the papules of lichen are developed; and their appearance, 
under these circumstances, seems to warrant the designation which I 
have given to the eruption, namely, lichen corymbosus, 2 for the 
papules in this case are grouped in clusters, varying from three or 
four to thirty in number, and suggest forcibly to the mind the idea of 
clusters of fruit. 

Sometimes the lichenous papules, instead of being arranged in 
groups, are dispersed singly over the surface of the skin, constituting 
a lichen disseminatus ; 3 and at other times they are packed almost as 
closely as the pores which they represent, lichen confertus. 4 

The transition of syphilitic roseola into lichen is so obvious, that 
it may be observed through every stage of its progress. A roseolous 
patch may be seen to develop papules by the mere swelling of the 
pores of the congested skin ; and the small papules of lichen are 
occasionally converted into those larger elevations which are known 
as tubercles, by a sudden aggravation of the syphilitic fever, or from 
exposure to cold. 

In a few instances I have seen the eruption of syphilitic lichen 
developed into the form of ring, constituting a lichen syphiliticus 
annulatus ; 6 and a lichen syphiliticus pustulosus may be distinguished 

1 Portraits of Diseases of the Skin, Plate XXXIV., M. 

2 [bid., Plate XXVI., AH. 3 Ibid., Plato XXVIII, 0. 

* Ibid., Plate XXV, AL. 5 Ibid., Plate XXVII., AN. 



SYPIIILODERMATA, OR SYPHILITIC ERUPTIONS. 389 

as resulting from a pyogenic action in the- papule, the consequence of 
irritability of system, or depressed vital powers. 

In a case of lichen corymbosus the papulas offered some variety in 
point of size, those of medium bulk being about equal in magnitude 
to a millet-seed. They were of a dull red or purplish hue, and were 
collected into groups or clusters, varying in number from three or 
four to thirty. The majority of the clusters contained ten or twelve 
of these pimples ; and, here and there, a few solitary ones might be 
observed dispersed among the clusters. The patch of skin on which 
the clusters were placed was slightly raised, wrinkled, and of a dull 
red hue. After a week of treatment the greater part of the pimples 
had subsided, and were each covered with a little, thin, brownish 
scale of desiccated epidermis ; there was also an epidermal exfoliation 
from the altered skin which formed the ground of the patch. The 
patches had become brownish in hue, and contrasted strongly with 
the color of the adjacent skin, although the latter presented the 
muddy and yellowish tint of syphilitic cachexia. Some few of the 
pimples, however, still lingered, and contained at their summit a 
whitish pus, and here and there a single fresh pimple showed itself. 
At the end of another week every pimple was gone, and the ground 
of the patches was undergoing a general exfoliation. 

In another case, one of lichen disseminatus, the eruption chiefly 
occupied the back and arms, but numerous pimples were scattered 
over the rest of the body and face. The pimples were large and 
isolated, of a dull red color, attained their full growth in the course 
of a few days, and then became filled at their summit, some with a 
turbid, sero-purulent fluid, and others with a whitish pus. 

Another mode of termination of the pimples is sometimes met 
with, as in a case of disseminated lichen, in which the pimples on. the 
face were of the usual yellowish red or copper color, which accom- 
panies the syphilitic cachexia ; they were large, prominent, and 
smooth, measuring one line in breadth by half a line in height, and 
rose abruptly from the unaltered skin. The aperture of a follicle was 
apparent on the summit of each, marking the seat of the inflammatory 
congestion to be the capillary plexus of the follicle. The summit was 
evenly rounded, not conical as in acne, and, unlike the latter, they 
were soft to the touch, and had no tendency to suppurate. At the 
end of a week they had a yellowish tint at the summit, which arose 
from the; thickening and commencing separation of the epidermis, 
and still later they were surmounted by a small conical crust, of a 
dirty-yellow color, consisting of desiccated sebaceous secretion, and 
reminding one of the conical crusts of rupia. After a time the little 
cap of thickened epidermis fell off, or where the conical crust of con- 
creted sebaceous matter had formed, this also separated, and the 
pimple gradually subsided to the natural level of the skin, leaving 
behind it a brownish stain. 

In their growth, maturation, and decline, these pimples, therefore, 
offer three stages for consideration: in the first they are smooth and 
soft, and the color is vivid ; in the second they are denser in structure, 
their color is dull, and they are surmounted by a small, yellowish 



390 DISEASES FROM THE SYPHILITIC POISON. 

crust of hardened epidermis and sebaceous substance ; in the third 
stage, they are declining. 

SYPHILODERMA TUBERCULOSUM. 
TUBERCULA SYPHILITICA. 

The tubercular eruption differs from lichen only in the size of the 
little elevations which give it its specific character. In lichen they 
are mere pimples, averaging from half a line to a line in diameter, 
and representing the immediate circumference of one of the pores 
of the skin. Tubercles, on the other hand, have a minimum size 
greater than that of the pimples of lichen, the smallest measuring 
upwards of a line in diameter, while some that I have observed had 
a diameter of three-quarters of an inch, and even more. They include 
many pores, and often a considerable portion of the skin. In other 
and essential respects there is less difference between them ; both 
result from the action of the syphilitic poison in the skin ; both may 
be a mere transformation of roseola. I have already adverted to the 
transition of roseola into lichen, and roseola into tubercula ; and the 
conversion of lichen into tubercula is by no means uncommon. 

Tubercles present some differences among themselves in respect of 
color, form, density, and elevation ; and they also differ in the manner 
of growth and arrangement. In point of color they are sometimes 
of a yellowish red, sometimes of that deeper hue which is known as 
"copper-colored," and sometimes purplish and brownish. In form, 
they are round, oval, or oblong, in the latter case being frequently 
crescentic in shape. In density they are sometimes soft and flabby 
to the touch, at other times firmer, but never hard ; and, as regards 
elevation, they rarely exceed one or two lines, but are sometimes 
almost flat. In growth, they sometimes spread in irregular rings, and 
sometimes the separate tubercles have a tendency to assume the 
annular character ; in one case the annular disposition being limited 
to a mere central depression (cupped tubercles), and in another 
extending to a perfect ring of considerable size. 

The color of syphilitic eruptions is often referred to as a pathogno- 
monic character, and it is quite true that they present in general a 
remarkable dulness of hue, such as would result from an admixture 
of brown, in various proportions, with the three primary colors, red, 
blue, and yellow. The early stage of development of the eruption is 
that which possesses the greatest amount of red ; in its second stage, 
and even in the primary when developed in a languid constitution, 
the slower circulation of the blood through the capillaries, and the 
consequent carbonization of the blood, gives a bluish tint to the color, 
in other words, forms a shade of the secondary color, purple. In a 
third stage of the eruption, when the vascularity is subsiding, and 
renders visible the staining effects of the yellow element of the blood 
upon the tissues of the skin, the color approaches towards the secon- 
dary orange, or with less red becomes a grayish yellow. So that the 
same eruption, seen at different periods, may be a red of greater or 
dulness, a purplish red, or a yellowish red; and the same differ- 



SYPHILODERMATA, OE SYPHILITIC ERUPTIONS. 391 

ences of color may be distinguished in different individuals from the 
beginning of the eruption. 

The color brown is called a neutral color, that is, it is neither red, 
blue, nor yellow; but at the same time a compound of the three. 
Hence the dirty hue of the skin in syphilitic cachexia is the result of 
the mal-composition of the blood, and consequently, of the secretions; 
the excess of blue is probably occasioned by the presence of a surplus 
quantity of carbon ; and the yellow, by a surplus of the pigmentary 
principle which gives color to the serum, the urine, and the bile. 
The admixture of this brown color with the red and purple of com- 
mon vascular congestion produces the dull or dirty red and purple 
above spoken of; and, in like manner, the bright, or rather clear, 
yellow stain of an ordinary bruise, would become a dull or dirty yellow 
by a similar admixture. 

In making these remarks, I am supposing the red to be the archseus 
or predominating color ; the eruption is primarily red, the red having 
a blending with blue on the one hand, and yellow on the other, but 
in both instances being rendered dull by the presence of brown. We 
have now to consider a series of tints in which the neutral admixture 
brown predominates. The brown may have an excess of blue in its 
composition, and be a dark brown; it may have an excess of red, 
and be a red brown; or it may possess an admixture of yellow in 
different proportions, and be an orange brown or a yellow brown. Now, 
of all these separate tints, the red brown with a slight admixture of 
yellow is that which most nearly approaches the hue of dull copper, 
and is, therefore, the type of the "copper-colored" eruption; the so- 
called copper color being, in fact, a reddish yellow brown. 

I have felt the necessity of giving this explanation of the precise 
meaning of " copper color," from having observed that medical men 
were not agreed as to the color to which this name should be applied, 
and, consequently, that it was liable to be employed more loosely than 
is consistent with scientific accuracy. The copper color represents, in 
fact, a declining stage of the eruption, when the congestion is subsid- 
ing, and the yellow stain of the altered fluids of the skin shines through 
the purple of the blood. The "copper color," therefore, may have a 
greater or less amount of red and yellow in its composition, and be 
either a reddish copper color or a yellowish copper color. 

As the copper color represents only a stage of an eruption, that 
eruption having probably passed through the tints of dull red, and 
dull purplish red, before it reached the reddish-yellow brown of copper 
color, it is clear that the term is objectionable, when taken as a 
pathognomonic sign of a syphilitic eruption. For if we see the erup- 
tion :it any other period than that of its decline, the characteristic tint 
is absent. 

hi the loose manner of using the term "copper-colored," above 
referred to, I have frequently heard l ho dull purplish red, the muddy 
rod, and the yellowish red, designated by that term; These colors, 
however, are by no means pathognomonic of syphilitic eruptions; 
they are commonly mot with in chronic eruptions of other kinds; 
for example, in acne. Any one looking upon a case of indurated and 



392 DISEASES FROM THE SYPHILITIC POISON. 

chronic acne, associated, as is commonly the case, where the eruption 
depends upon mal-assimilation, with a sallow and muddy skin, must 
be struck with the close resemblance of such an eruption to one of 
syphilitic origin. Indeed, I have often seen non-syphilitic eruptions 
possessing more of the dull and muddy hue, which is generally sup- 
posed to be characteristic of syphilis, than syphilitic eruptions them- 
selves. The color of eruptions of the skin must not, therefore, be re- 
lied on as proof of their syphilitic nature, although it may be fairly 
taken as a pathognomonic character where other symptoms tending to 
the same diagnosis are found to be present. 

Syphilitic tubercles present some varieties which have reference to 
obvious diversities of character of development. For example, some 
are collected into patches of variable size, and are distributed, more 
or less generally, over the surface of the body; they correspond in 
manner of distribution with the corymbose form of lichen; hence, I 
have named them tubercula corymbosa. Others constitute groups 
which are more or less solitary in their arrangement, and of variable 
size. The group is bounded by a distinct border of tubercles, which 
creep along the skin, and increase gradually the dimensions of the 
patch. The circumscribed character of such a patch suggests the 
name of tubercula circumscripta. 1 Others are scattered over one or 
several regions of the body as separate tubercles, tubercula disseminata ? 
in some, the tubercles merge into each other and form a smooth bank, 
which expands into the form of a ring, tubercula annulata; while 
others, again, belonging to either of the preceding groups, are apt to 
take on an ulcerative action, and establish a variety which may be dis- 
tinguished as tubercula ulcerantia. 

Tubercula corymbosa. — In a well-marked case of tubercula corym- 
bosa, the eruption consisted of soft, yellowish-red tubercles, with 
rounded summits, and but little raised above the level of the skin. 
The average size of the tubercles was one line and a half; when 
isolated they measured two lines, and there were some which reached 
four lines in diameter. They were dispersed irregularly over the 
surface of the skin, and had a general distribution in patches of 
various size and form ; in some situations the patches being as large 
as the palm of the hand; in others, small, and scattered between the 
former. On a close examination, it became apparent that there was a 
prevailing disposition on the part of the tubercles to form circles or 
rings, and this character was discernible even in the large patches, 
which seemed to be composed of a number of rings confusedly clus- 
tered together. The rings varied much in size, some having a mere 
central depression, and measuring scarcely more than a quarter of an 
inch in diameter, while others had an ample area, and measured from 
an inch to an inch and a half. The tubercles presented some differ- 
ences of appearance common to these eruptions during the progress 
of the disease. In the first instance, while the congestion was active, 
they were bright in color and perfectly smooth on the surface; when 

' Portraits of Diseases <>f the Skin, Plate XXX., A B. 
2 Ibid., Plate XXIX., N. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 393 

the congestion was on the decline, they lost their brightness of hue, 
and looked faded and shrunk, the epidermis covering them having 
become opaque and wrinkled. Later still, the epidermis became dry, 
cracked around the circumference of each tubercle, and peeled off, 
leaving a fringe around their base, and sometimes a small scale, the 
last remains of the exfoliating cuticle, on their summit. When the 
tubercles subsided altogether, leaving behind them brown stains, the 
skin presented a very remarkable appearance. The stains formed a 
number of brown rings, edged with a narrow margin of cuticle, and 
inclosing a centre of natural skin. In this state the eruption would 
pass very well among the inexperienced for a declining lepra, and the 
broken laminae of desquamating epidermis suggests a motive for con- 
sidering it a squamous affection. 

While the general characters of the eruption may be such as are 
now described on the body and limbs, it is not unfrequently consider- 
ably modified when developed on the face. Thus, in another case, 
the countenance of the patient was deformed by a tubercular erup- 
tion, of a dusky-red hue. On parts of the face, and particularly on 
the exposed portions of the neck, the eruption consisted of distinct 
rounded tubercles, of large size. On other parts of the face, the tuber- 
cles had the form of oblong mounds, more or less curved, and again, 
in other situations, formed complete circles. On the forehead, the 
tubercles appeared to have become blended together, so as to constitute 
one single tuberous mass, of irregular shape, which extended across 
the brow, from one temple to the other. This mass was of a dusky 
red color, with a tinge of yellow, which gave it a coppery hue, and 
there was a seeming transparency about it which made it resemble 
brawn, or a portion of coarse and thickened skin, in a state of oedema, 
from infiltration of a yellow serum. To the touch, however, the 
swelling was hard, and evidently occasioned by a thickening of the 
skin, and not by the infiltration of fluid. 

The trunk, as far as the waist, and the arms, were covered with the 
eruption, *the tubercles being more or less developed, and the corymbi 
more or less annular. In certain situations the tubercles were less 
fully formed, ami appeared to be made up of a number of papulge, 
very little larger than those of common lichen ; and many of these 
smaller pimples, of a dirty hue, were scattered amidst the patches of 
eruption, or grouped around the clusters of tubercles. 

On the lower limbs and lower half of the trunk of the body, the 
clusters of tubercles had subsided to the level of the skin, forming so 
many darkish-red or brownish stains (macuhe') of a circular form. 
Many of these maculae were sprinkled over with the dark remains of 
the papules, or with deeper-colored spots, which indicated the pores 
of the follicles. The maculae were, for the most part, dark in the 
centre, fading away gradually to the circumference, and in some situa- 
tions had the appearance of the stains of a bruise. 

The general surface of the skin was dry, sordid, and discolored, and 
presented the character so constantly met with in cutaneous syphilis. 

Turercula circumscripta. — The eruption of tubercula corymbosa 
is general and acute ; the eruption of tubercula circumscripta belongs 



304 DISEASES FROM THE SYPHILITIC POISON. 

to a later period in the existence of the poison, and is, consequently, 
partial and chronic. It occurs in patches, which vary in size from two 
to twelve inches in diameter ; they are solitary or few in number, 
rarolv exceeding six or eight; they consist of a confused assemblage 
of tubercles, among which there is an obvious tendency to assume 
a circular arrangement, and they are distinctly circumscribed, the 
boundary being formed by a line of tubercles. 

The following is an illustration of tubercula circumscripta, appear- 
ing four years and a half after contagion ; the subject was a man of 
thirty, and the number of patches seven, one large and six small. 
The large patch measured nearly eight inches square, and covered the 
greater part of the left side of the abdomen. It was composed, as 
were the others, of numerous dull-red tubercles, having an average 
measurement of two lines in diameter, dispersed, apparently, without 
order, upon a ground of a dirty brown hue. and bounded by an irregu- 
lar and slightly raised margin ; in several places the tubercles had a 
circular arrangement, the rings being more or less complete. The 
smaller patches, about two inches in diameter, consisted of an irregu- 
lar ring formed by a slightly elevated, reddish margin, inclosing an 
area of a yellowish-brown color, over which the eruption had crept. 
Within this area the epidermis was somewhat more wrinkled than 
that of the surrounding skin ; and in the greater number of the patches 
there were scattered here and there one or two tubercles, which re- 
mained in a chronic state, while the rest had disappeared. 

In their irregularly circular form and marginate character, these 
patches bear a near resemblance to lepra in the state of retreat ; even 
the scattered tubercles within the circles are met with in lepra. But 
there are certain strongly distinguishing characters between lepra and 
the leproid forms of cutaneous syphilis, namely, the coppery, or dull- 
red color of the latter, the yellow-brown stain which they leave behind 
on the skin, after their decline ; the softness of the syphilitic tubercles, 
as compared with those of lepra ; and, lastly and chiefly, the total 
absence of squamae. In old syphilitic tubercles, the epidermis may 
frequently be seen in a state of exfoliation ; but the thin, ragged films 
of exfoliating epidermis, peeling from their summits, are easily dis- 
tinguished from the thick, circular, morbifically elaborated scales of 
true lepra. Moreover, in a syphilitic patch of the kind now described, 
the cuticle may generally be traced unbroken from margin to margin, 
over the whole surface of the diseased skin. 

If the large syphilitic patches (two inches in diameter) be examined 
carefully, and at various stages, with reference to their mode of devel- 
opment, they will be found to originate in simple tubercles, disposed 
in irregular circles of four, five, or six. The skin, included within 
and between these tubercles, partakes of the morbid action ; the 
tubercles become fused at several points, forming an elevated margin ; 
and the margin extends by its outer lip, and increases the area within; 
In this way, a number of small rings, measuring about half an inch 
in diameter, and creeping onwards by their circumference, become 
blended so as to form a single patch. The onward growth is then 
taken up by the peripheral margin of the collective patch (hence its 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 395 

irregular outline, and its obvious composition of segments of small 
circles), the tubercles and margins left within the greater margin sub- 
side more or less completely, by virtue of a tendency on the part of the 
disease to cease on the exhausted ground, and prey upon the juices of 
the neighboring untainted soil ; and, after a time, nothing of the origi- 
nal elements of the disease remains — all is lost but the slightly eleva- 
ted reddish margin, and its sombre leaf-brown area. 

In a case in which there existed a single patch of large size on the 
shoulder, the eruption commenced as a mere pimple, which increased 
to the size of a split pea ; some months afterwards, a second pimple 
appeared, and having attained the dimensions of a small tubercle 
both began to spread out, and assume a circular form ; then one or 
two tubercles rose up between the rings, and connected them, and in 
the course of a month, the whole together completed a patch as large 
as a hand. The annular character of the patch was well marked, the 
boundary being formed of a broken line of confluent tubercles, which 
were flattened, and surmounted by a thin covering of dry and desqua- 
mating epidermis. There were several tubercles with desquamating 
summits within the areae of the rings, and the skin forming the ground 
of the patch had a reddish brown tint. 

When the patches of tubercles appear on the face and exposed part 
of the neck, they have a brighter color than elsewhere. This was the 
case in a woman, the side of whose face and forehead was covered with 
a patch of a bright copper color, which had continued in the same 
state, with very little change, for twelve months. 

On their subsidence, the patches of tubercula circumscripta some- 
times leave very little trace of their existence on the skin ; at other 
times, they leave a brown stain ; sometimes an injected state of the 
skin, and sometimes shallow pits. The copper color of the patches 
owes a part of its intensity to a magnified capillary plexus, and 
numerous meandering venules, which may be seen on a close exami- 
nation of the skin. Often, the tubercles seem to possess the power of 
disorganizing the structure of the skin completely, without suppura- 
tion and without ulceration ; hence, when they disappear, they seem 
to be absorbed, and with them that portion of the skin which they 
had assimilated to their own structure, and they leave behind them 
deep and permanent pits, and, where they are of large size and extent, 
strongly marked cicatrices. The vascular congestion and shallow pits, 
arc both characteristic of the chronic form of syphilitic tubercular 
eruption of the skin. 

TUBEKOULA disseminata. — The disseminated form of tubercular 
eruption is less acute and less general in its eruption than tubercula 
corymbose ; thus evincing a later period of the poison, but more 
acute and more general than tubercula circumscripta; occasionally it 
baa ln( 11 met with conjoined with the former. The tubercles are 
larger thai) those of the clustered eruption, perfectly round, and but 
little elevated above the surface of the skin ; in their appearance and 
elevation suggesting an appellation by which I once distinguished 
them, namely, tubercula lentiformia. In point of measured size, the 
medium diameter of the disseminated tubercles may be roughly stated 



396 DISEASES FROM THE SYPHILITIC POISON. 

to be four lines, while that of the clustered tubercles is two lines and 
a half. 

In the case of a } T oung woman, aged twenty-two, the eruption of 
tubercles covered the face, neck, and upper region of the back, some 
few being scattered over the arms. The}'- first appeared on the face, 
and gradually extended downwards. The tubercles were perfectly 
circular, isolated, and lentil-shaped, of a dull red, almost livid color, 
smooth and uniform in size, measuring about a quarter of an inch in 
diameter. On the neck, the tubercles were less numerous than on the 
face, but somewhat more prominent and larger, one or two measuring 
more than half an inch in breadth. On the back of the neck, and 
between the shoulders, were about fifty tubercles, for the most part 
isolated; some few, however, were grouped in pairs, and in two 
instances, a pair had become blended together. They were all exactly 
circular, and more prominent than those of the neck, but the most 
prominent, even here, measured only three-quarters of a line in eleva- 
tion. In breadth,, the extremes of measurement ranged between one 
line and six (half an inch) ; the size of the greater number was five 
lines; the next common size measured two lines and a half; while 
below these were a number of smaller papules scattered among the 
rest, and representing either the common papules of syphilitic lichen, 
or the early stage of growth of the tubercles. The developed tuber- 
cles presented every degree of completion and decadence ; some were 
smooth, others wrinkled, others beginning to desquamate, and in others, 
desquamation had advanced some stages. 

In my observations on this case, I remarked that the tubercles are 
exactly circular in form, varying in size from one-quarter to three- 
quarters of an inch in diameter, very slightly raised above the level 
of the adjacent skin, evenly convex on the surface, and subsiding 
gradually from the centre to the circumference, which merges insen- 
sibly into the surrounding skin. In point of elevation and form, they 
have very much the appearance of split lentils laid upon the skin, 
only that they are much broader. Their color varies from a bright 
coppery red, to a dull, dirty crimson. Their epidermal covering 
varies with their stage of growth ; in the first instance, when the 
tubercles are tumid, the cuticle is smooth, and they have a polished 
appearance ; later, when the congestion of their vessels diminishes, 
the cuticle is wrinkled ; and later still, the cuticle becomes loosened 
from their surface, cracks, and separates. Sometimes, but rarely, they 
pass into a state of ulceration, the ulcer commencing on the summit of 
the convexity. 

The manner in which the exfoliation of cuticle commonly takes 
place from the surface of the tubercles is the following : the cuticle 
cracks in a circular direction, just within the boundary of the eleva- 
tion, and then separates gradually from the surface beneath ; the cen- 
tral piece separating towards the centre of the convexity ; the peri- 
pheral piece separating towards the sound skin, and forming a kind 
of frill around its margin. A crop of tubercles may sometimes be seen 
presenting every gradation of this process of desquamation at the same 
moment. There are some in which the crack has just taken place; 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 397 

others, in which the edge of the central piece has been worn away, 
and has become reduced to a small disk, occupying only the central 
part of the convexity ; others, in which the central piece is entirely 
gone ; some in which the peripheral portion is distinct ; others, in 
which it is partly, and others, again, in which it is wholly, removed. 
The tubercle may now be left quite smooth, or secondary exfoliations 
may commence. The latter, however, are for the most part irregular 
and partial, and are not to be confounded with the primary exfolia- 
tion first described. When ulceration occurs, a crust is formed on 
the ulcerated surface ; and, in proportion to the quantity of pus 
secreted by the ulcer, or the care with which it is kept, the crust may 
become very thick, or be a mere scale. 

The tubercles of the disseminated variety of the syphilitic eruption 
are sometimes less distinctly round than those just described, less 
raised, and sometimes smaller, making it difficult to determine whether 
to class them under the head of roseola, lichen, or tubercula ; but the 
elevation of the centre of the spots, although very slight, and the 
manner of exfoliation of the cuticle, generally determine the nature 
of the eruption when it belongs to the present group, assuming for the 
tubercles as a distinction from the "lentiform" kind, the designation 
of "flat." 

Tubercula annulata. — The type of the present form of eruption 
is a tubercle, which spreads in a circular direction, so as to form a ring 
of variable breadth. Sometimes the tubercle itself seems to enlarge 
and constitute the ring, leaving an area in which the skin returns by 
degrees to its natural state ; at other times, the tubercle would appear 
simply to communicate the impulse of growth to the skin immediately 
about its circumference, a ring being formed around the tubercle, and 
gradually enlarging, while the tubercle remains stationary in the midst 
of the area. It is to . this form of syphilitic tubercle that the term 
syphilitic lepra has been applied, and the resemblance is so great as to 
give a certain warrant to the error. The eruption is sub-acute and 
partial in its distribution, and appears to result from the agency of a 
modified poison. 

In the case of a young woman who suffered under this eruption, the 
tubercles were scattered over various parts of the body, but were most 
numerous about the neck. They commenced on the fore-arm by two 
spots, and gradually extended, first to the neck and hips, and then to 
her limbs. On the neck the eruption presented every stage of pro- 
gressive development. There were papules scarcely a line in diameter ; 
tubercles, measuring from two to four lines ; circular patches three or 
four lines across, with depressed centre, and raised border ; raised and 
papulated rings from half an inch to one inch in breadth, of a circu- 
lar or oval figure, inclosing in their centre a large and irregularly- 
shaped tubercle ; and one or two rings with a smooth area. 

Many of the patches were in the state of desquamation ; the exfolia- 
tion of the cuticle being chiefly apparent on the summit of the central 
papules, and upon the convexity of the rings. The scales, however, 
were obviously nothing more than desiccated epidermis, and very 



398 DISEASES FROM THE SYPHILITIC POISON. 

thin; and not, as in the case of lepra, epidermis altered in its anato- 
mical structure, and thick and laminated. 

Sometimes the central tubercle spreads with the ring, and the whole 
seems to form one broad, soft patch, the ring being distinguished from 
the tubercle by a mere groove. In one case there were several of 
these broad fleshy tubercular patches bounded by an abrupt border. 

In another case, that of a young man of twenty, the entire number 
of spots or patches did not exceed twelve or fifteen, and were distri- 
buted upon the hips, thighs, and penis. Of two spots on the right hip, 
one was irregularly circular, the other oval ; the former measured one 
inch and a quarter, the latter one inch and a half in longest diameter. 
They consisted of a central, broad, and fleshy tubercle, surrounded by 
a raised ring; both the tubercle and ring were of a deep, dull-red 
color, and the redness extended over the whole of the area included 
within the ring. The tubercle was wrinkled and smooth on the sur- 
face ; the ring was marked by numerous transverse furrows, and was in 
a state of desquamation, the portions of desquamating epidermis cor- 
responding in shape with that of the intervals between the wrinkles. 
On the right thigh there were four patches, one was a simple tubercle 
measuring one line and a half in diameter; it represented the first 
stage of growth of the patch ; another was a raised, flat, oval-shaped 
tubercle, half an inch in diameter, and appearing, from the elevation 
of its border, to be slightly depressed in the centre; the remaining 
two measured an inch, and an inch and a half in diameter, were oblong 
and oval in shape, and had each a broad and irregular central tubercle. 
Of the three patches on the penis, the largest, measuring an inch in 
longest diameter, had a central tubercle ; the other two were smaller, 
and mere rings, inclosing an area of brownish and slightly corrugated 
skin, over which the ring had crept in its onward growth. 

The resemblance of these patches to those of lepra vulgaris was very 
striking, and I have no doubt that they would have been called lepra 
syphilitica by any one who had seen them ; and yet their origin and 
mode of development was identical with that of tubercular syphilitic 
eruptions in general. They differed from lepra, however, in the 
absence of scales, an important point; and also in the presence of the 
central tubercle; the patches of lepra are depressed in the centre; 
these were more elevated in the centre than at the circumference. 

In another example there was no central tubercle, and the eruption 
had more of the character of lepra vulgaris than the preceding cases. 
The patient was a medical student ; he consulted me for an eruption, 
which he considered to be common lepra, and its appearance was 
certainly such that it might have deceived men of more experience 
than himself. On the lower limbs were fifteen or twenty large rings, 
of a medium size of two inches in diameter. The area of the ring 
was perfectly smooth, and of ajrellowish brown color; the ring itself 
was raised, of a dull-red color, and irregularly circular or oval in its 
form. On the side corresponding with the area, the elevated margin 
rose abruptly from the surface ; on the peripheral side it declined 
gradually to the level of the surrounding skin. The breadth of the 
rings was between three and four lines. The surface of the rings 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 399 

presented certain differences of appearance ; in some, it was uniform 
and smooth ; in others, the rings were marked by numerous transverse 
wrinkles; and others, again, were either papulated on the surface, or 
looked as if formed by the aggregation and fusion of numerous tuber- 
cles. There was a slight condensation of the cuticle covering some 
of the rings, and here and there an indication of epidermal exfoliation. 

Tubercula ulcerantia. — One of the most striking of the pecu- 
liarities of syphilitic cutaneous disease, is the gradual and almost 
imperceptible transition by which one form passes into another. We 
have seen this peculiarity illustrated in the transition of roseola into 
lichen and tubercle; in the close alliance subsisting between the 
varieties of tubercles ; and the same fact is perceptible in the gradual 
conversion of tubercles into ulcerations. These observations all point 
to the unity of the syphilitic poison; and the varieties evinced in the 
manifestation of the morbid effects of the poison, are such as might 
be anticipated from a knowledge of the varieties of constitution pre- 
sented by mankind, and the varied conditions to which the poison 
must be subjected in its numberless mutations. 

Even ulceration is presented to us in a transition state, in that 
curious phenomenon wherein a tubercle disappears, or is removed by 
absorption, and leaves behind it a deeply pitted cicatrix, without any 
external signs of ulceration being perceptible ; sometimes a slight 
crust is formed on the subsiding mass ; at other times, and especially 
under the influence of mercury, it sinks and is lost without a trace of 
change in its outward appearance. In another series of cases a thin 
crust covers the summit of the subsiding tubercle ; if Ave remove the 
crust a little moisture of an ichorous nature may be perceived, per- 
haps a globule of purulent secretion. We might be inclined to admit 
that there was a slight abrasion of the surface, but scarcely that there 
existed a condition to which we could correctly give the name of 
ulceration. In a third series ulceration is unquestionable, but the 
nature of the ulceration of the superficial kind. 

SYPHILODERMA PUSTULOSUM. 

RUPIA SYPHILITICA. 

The only eruption coming strictly under the denomination of 
pustular syphilis is rupia ; an affection depending especially on a 
pyogenic condition of the constitution. Other forms of pustule must 
be considered as instances of suppurating papules and tubercles. I 
have myself fallen into the error of denominating a pustular eruption, 
produced under the impulse of constitutional syphilis, "impetigo syphi- 
litica;" 1 upon further reflection I think it would have been more 
correct to have regarded it as a lichen passing into the state of suppu- 
ration. Such cases are by no means rare, and a pustular lichen may 
be fairly admitted among the occasional phenomena of that eruption. 
I recollect an instance in which the greater part of the papules devel- 
oped on the arms and legs of a syphilitic patient were gradually con- 

1 Portraits of Diseases of the Skin, Plate XXXI., Y. 



400 DISEASES FROM THE SYPHILITIC POISON. 

verted into pustules. The syphilitic ecthyma seems to me to be also 
doubtful, but not so positively unlikely as the production of smaller 
pustules. Even in the instance of ecthyma it is necessary that we 
should be well assured that the case is not one of suppurating tubercle. 

Rupia 1 (Plate VIII.) is characterized by the eruption of small 
purulent bullae or large pustules, which are few in number, dispersed, 
and surrounded by a narrow zone of redness. The bullae contain, in 
the first instance, a serous or sero-purulent fluid, which speedily 
becomes purulent or sanguinolent, and concretes and desiccates into 
dark greenish or blackish rough crusts. These crusts are variable in 
point of thickness ; the larger ones bear some resemblance to the 
shell of the oyster ; whilst others are conical in their form, being 
thicker in the middle than at the circumference, and not unlike the 
shell of the limpet. When the crusts fall off they leave behind them 
atonic ulcers of a circular form and various depth, which secrete an 
abundant, ichorous, purulent, and fetid fluid, and are indisposed to 
heal. Rupia is tedious in its progress, and lasts for several weeks or 
months. 

The varieties of rupia are founded on the extent and severity of the 
disease, and on the thickness and form of the crust ; they are — 
Rupia simplex, Rupia prominens. 

RUPIA SIMPLEX. 

Ecphlysis rhypia, Mason Good. Sordid Main. 

In rupia simplex (Plate VIII., L, M, n), the purulent bullae are 
circular in form, flattened on their summit, and equal in diameter to 
a sixpenny or shilling piece. When first developed, they contain an 
opaline fluid, which soon becomes purulent, and gradually concretes 
and dries up. As the secretion dries, the epidermis around it shrivels, 
and eventually forms a brownish, wrinkled crust, somewhat like the 
outside of an oyster-shell. The crust is thickest in the middle, and 
is continuous at the circumference with the epidermis of the sur- 
rounding skin. It is thrown off after some days, and exposes a red 
surface, or a superficial ulcer, which may continue for several days 
longer. In the latter case a new crust is formed by the desiccation 
of the secretion upon the surface of the ulcer, and a succession of 
crusts may in this way be produced. When the ulcer heals its seat 
is indicated by redness or lividity of the skin around the cicatrix, 
which endures for a considerable period. The more frequent situa- 
tion of rupia simplex is the legs and lower parts of the body. 

RUPIA PROMINENS. 

The prominent rupia (Plate VIII., o) receives its designation from 
the projecting and conical form of the crusts which succeed the 
purulent bullae. The pustules are of greater extent than in the 
simpler variety, and are followed by a troublesome ulcer of consider- 
able depth. 

1 Der. /Svttsc, sordes. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 401 

Rupia prominens is preceded by several circumscribed patches of 
erythema or by tubercles, upon which the epidermis is raised slowly, 
and is distended with a turbid, dark-colored fluid. The fluid soon 
becomes concreted, and gradually desiccates into a thick and wrinkled 
crust of a brownish-black color. While the crust is proceeding 
towards completion, the erythema slowly extends its limits, so as to 
form a narrow areola around the circumference of the crust. Upon 
this areola the epidermis is raised, and a fresh secretion of purulent 
fluid takes place beneath it, which increases the breadth of the crust. 
In this manner, by successive secretions, extending each time beyond 
the limits of the first formed scab, the crust is gradually enlarged at 
its base, and raised more and more above the surface, so as to assume 
the characteristic form of the limpet-shell. From its mode of growth 
the crust appears to be formed of concentric layers, projecting one 
beyond the other like tiles upon a house-top, and when it enlarges in 
breadth more than in height, it bears a close resemblance to the scaly 
shell of an oyster. The crust goes on increasing for several days, 
sometimes for a week, and then becomes stationary. In this state it 
remains for a variable period, being at one time easily detached, and 
at another firmly fixed. When detached, either spontaneously or by 
accident, it is found to conceal an ulcer of considerable depth, and of 
variable extent, being deep in proportion to the duration of the crust. 
The ulcer, when thus exposed, sometimes secretes a new crust, which 
grows thick by successive additions from beneath. At other times, 
and this is the more frequent course, the ulcer retains its open form, 
presenting a foul surface, thin, livid, or pale, and excavated edges, 
and an inflamed areola. The ulcer is difficult to heal, and after the 
formation of a cicatrix, leaves a livid and purplish stain which con- 
tinues for many months. 

This form of rupia occurs both on the upper and the lower limbs, 
but more frequently on the latter. The bullae are sometimes few in 
number, sometimes numerous and successive; usually, however, there 
is one only or a few at their height, while others may be threatening 
to appear or on the decline. Sometimes the pustular bullae, instead 
of pursuing the tardy course described above, is developed quickly, 
and is filled with a lymph, which subsequently becomes opaque and 
purulent. In other instances, again, the inflammatory redness may 
be dissipated without the appearance of a bulla. 

In rupia the pyogenic constitution may be idiopathic or accidental, 
nr both, as in the case of a young man of twenty, who received the 
infection of syphilis while in a debilitated state from immersion in the 
water during the winter season. He had a chancre and suppurating 
bubo; the former healed readily, but the latter confined him to bed for 
nine weeks. Six weeks after inoculation a crop of red tubercles made 
their appearance on the face and head. The tubercles were round, as 
large as a split pea, and, after increasing in size for a few days, 
became filled in the summit with a bright yellow pus. Two or three 
days later the centre of the pustule had become brown, and was be- 
ginning to desiccate into a yellowish-brown scab. The margin of the 
scab, where it was continuous with the epidermis, was still yellow 

26 



402 DISEASES FI10M THE SYPHILITIC POISON. 

from the effusion of fresh pus, while a narrow halo of redness indicated 
the inflamed skin around its circumference. 

After another period of six weeks from the outbreak of the pre- 
ceding attack, he was seized with sore throat and severe pains in the 
limbs, which increased at night ; the fauces were much inflamed, and 
there was ulceration of the tonsils and pharynx. His face at this 
time was studded all over with yellowish-brown crusts; there were 
several on the scalp and a few on the limbs and back ; altogether the 
number distributed upon the face and head amounted to sixty-eight. 1 
The eruption presented itself in all its stages of development and 
growth : there were simple tubercles, others surmounted with yellow 
pus, and others covered with crusts possessing every gradation of 
growth. The crusts bore the aspect of being laminated; some were 
irregular ; others were pretty evenly limpet-shaped ; while a few were 
broken into small fragments, and had a mulberry-like appearance. 
Upon the eyebrows they had uprooted the hair and carried it with 
them, so that, on superficial inspection, they seemed tufted with hair. 
There was also some difference of color : in the most recently formed 
crusts a reddish-yellow predominated ; the older ones were brown, 
with a tinge of green or yellow ; and those which had been caught by 
the dress or by the bedclothes were black from being stained with 
blood. 

The elevation of some of the crusts was three-quarters of an inch, 
and such crusts had generally the conical shape (Rupia prominens, 
Plate VIII. o), that particular form being partly the result of freedom 
from injury, and partly the consequence of the slow and gradual 
peripheric extension of disease in the skin. On the side of the cheek 
one of the crusts was thicker below than above, from gravitation of 
the imprisoned pus ; and on the upper lip, near the margin of the 
prolabium, there were two, of a circular and conical form, which 
curved downwards to the mouth, and were not unlike the beak of a 
hawk. The largest of the crusts was situated on the front of the thigh, 
and measured nearly two inches in diameter ; it was dark-colored 
from effusion of blood, and thin. 

In its relation to the surrounding skin, the exterior pellicle of the 
crusts was continuous with the epidermis ; this portion of the pellicle 
was of a lighter color than the rest, and covered a layer of newly- 
eftused pus. By a little pressure the pellicle in this situation might 
be broken through all round, and by a slight increase of force, the 
crust might be removed entirely, showing it to be a hollow cone filled 
with a thick and tenacious pus, and based upon an indolent and un- 
healthy ulcer. 

The ulcers which constitute the base of the crusts of rupia have 
been aptly termed "atonic." When they have made but little pro- 
gress in depth, they present a coarsety granular surface, interspersed 
with irregular patches of undestroyed skin. A little later, when the 
ulceration reaches the deepest stratum of the corium, the tissue of the 
latter may be detected among the granulations, forming an open net- 

1 Portraits of Diseases of the Skin, Plate XXXII., W. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 403 

work ; while, at a still later period, the corium is entirely destroyed^" 
the exposed subcutaneous tissue is frequently smooth, or the granu- 
lations are few and scattered, and the hollows are filled with whitish 
and yellowish lymph. The edges of these ulcers are generally pale 
and smooth, without being raised, and they are undermined to a greater 
or less extent. When the ulcers of rupia heal, they leave behind 
them ugly cicatrices, with more or less of a purplish hue of the skin, 
and often a brownish stain. 

SYPHILODERMA PILARE. 
ALOPECIA SYPHILITICA. 

The fall of the hair, alopecia, sometimes follows the syphilitic fever, 
in the same manner as it is met with as a sequela of measles, scarlet 
fever, or fevers of any other type. Under the influence of the con- 
stitutional actions present in these fevers, the formation of the epider- 
mis and hair is temporarily suspended, the epidermis as a consequence 
exfoliates, and the hair falls. Where the fall of the hair is a chronic 
action, it probably depends upon insufficient nutrition of the skin ; a 
condition especially characteristic of the syphilitic cachexia. 

In a disease so important and serious as constitutional syphilis, the 
fall of the hair, even as a symptom, is not calculated to excite more 
than a passing notice. If it be sought for, it will be found very fre- 
quently ; but occasionally it is brought under our attention by the 
immediate inconvenience to which it gives rise. 

I am often consulted for alopecia where syphilis is not suspected, 
and in these cases I subject my patient to a careful scrutiny for the 
detection of any symptom which might indicate its dependence on the 
syphilitic poison. Sometimes I have succeeded in discovering such a 
symptom, however obscure, and then the treatment applicable to con- 
stitutional syphilis has been remarkably successful. In one case the 
concurrent symptom was a tendency to neuralgia; in another, a muddy 
skin, with occasional sore throat ; and in a third, a milky spot or a 
fissure on the tongue. 

The following is an example of alopecia, depending on syphilis : A 
gentleman contracted a venereal sore, the nature of which was doubted 
at the time by his medical attendant, and a week was allowed to 
transpire before he commenced taking mercury. He then took blue 
pill until his mouth was affected ; the sore healed in three weeks. 
Throe months after the sore, his hair began to fall off in considerable 
patches, and a month later he had sore throat. On the occasion of 
his visit to me the hair was falling abundantly, it was parched and 
shrunken as if dead, and the scalp was dry and scurfy. Upon exami- 
nation I found the stain of a syphilitic tubercle on the nape of his 
neck. 

SYPHILODERMA UNGUEALE. 
ONYCHIA SYPHILITICA. 

The matrix of the nails is not unfrcquently affected by redness, 
swelling, suppuration, and often ulceration, under the influence of the 



404 DISEASES FROM THE SYPHILITIC POISON. 

inflammation of syphilis, and the case is one of syphilitic onychia. 
Sometimes one finger or toe alone is attacked, at other times several 
may he affected at the same moment. The skin immediately around 
the nail is considerably puffed and swollen, often the whole extremity 
of the finger or toe is enlarged ; suppuration and superficial ulceration 
occur between the skin and the edge of the nail, fungous granulations 
are formed, which partly overlap the nail ; the suppuration extends 
beneath it, and the nail is, in consequence, more or less loosened. This 
state of disease is excessively painful, but quickly gets well under the 
influence of general remedies. 

Syphilitic degeneration of the nails is also met with occa- 
sionally as a consequence of the presence of the syphilitic poison in the 
blood. The nails are apt to be altered in structure, they are discolored 
and brittle, thinner or thicker than natural, and rough and fibrous in 
texture. Sometimes they fall off, and are succeeded by others more 
faulty than themselves, and sometimes this morbid condition of the 
nails is accompanied with erythema of the matrix, or of the skin im- 
mediately bordering the edge of the nail. 

SYPHILODERMATA PRIMITIVA. 

second period. 
Tertiary Syphilis. 

The effects of the syphilitic poison on the human constitution are 
so altered and modified by time, that the distinction of the constitu- 
tional symptoms of syphilis into secondary and tertiary is universally 
recognized. It does not, however, follow, that these are necessarily 
connected with each other in the order of their apparent sequence ; for 
the secondary or constitutional disease may be present without any 
primary disease having existed ; and the tertiary symptoms may be 
evolved without the intervention of any secondary affection. Nor 
does time necessarily bring about similar changes in similar periods ; 
the effects, besides being modified by time, also subserve the powers 
of constitution of the individual, and are consequently developed more 
rapidly in one person than in another. Again, the primary symptoms 
sometimes merge into the secondary, and the secondary pass so gra- 
dually into the tertiary, that it becomes often difficult to draw with 
certainty a line between them. These considerations must always be 
borne in mind in our observation of this class of diseases, and our diag- 
nosis as to the period of the disease must be founded, not merely upon 
time, but also upon decided pathological characters. 

The syphilodermata which belong to the second period, that is, to 
the period of tertiary syphilis, may be arranged under three heads, 
according as they present, in chief, the characters of erythema, of 
tubercle, or ulcer. To the erythematous group belong, psoriasis pal- 
maris et plantaris, and an erythema which occurs for the most part 
on the face, lupus erythematosus. Under the head of syphiloderma. 
tubereuhsum are to be considered, tubercula mucosa, tubercula ulce- 
rantia, superficial and deep, lupus ulcerosus, and tumores gummati; 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 405 

while the syphiloderma ulcerans exhibits one of the destructive attri- 
butes of syphilis when the latter has gaine'd long possession of the 
system. 

ERYTHEMA PALMARE ET PLANTARE, SYPHILITICUM ; VEL, PSORIASIS 
PALMARIS ET PLANTARIS SYPHILITICA. 

Erythema palmare commences usually in the middle of the palm of 
the hand, in one of the grooves of flexion, as a reddish spot, over 
which the cuticle becomes hard and yellow, from destruction of its 
vitality, and soon after cracks and exfoliates, leaving a red surface 
beneath, covered by a new epiderm. Sometimes this process com- 
mences at the same moment in both hands ; sometimes it exists in one 
only ; sometimes it takes place in the soles of the feet as well as in 
the palms of the hands. Often there is only one of these dry, red, 
cracking, uncomfortable patches on the hand ; at other times, there 
are several ; for example, around the ball of the thumb, on the wrist, 
in the lines of flexion of the fingers. The exfoliating erythematous 
patch may continue in the state now described for weeks, months, or 
years, with little or no change. Sometimes it exhibits a tendency to 
spread, and then it creeps slowly along the fingers to their tips, along 
their borders, around the borders of the hand, or upwards upon the 
wrist. ' Occasionally, and less frequently, it reaches the back of the 
hands and back of the fingers, and I once met with a case in which 
its principal seat was the back of the hand. But whether it be partial 
or general in its attack on the hand, it is always the same red, inflamed, 
hot, cracked, exfoliating surface ; sometimes, but rarely, the tender 
derma, newly exposed by the peeling off of the skin above, cracks, 
then a little blood escapes, and the crack heals ; sometimes the dry, 
cracked cuticle is- the cause of the fissure of the skin ; rarely, a little 
suppuration takes place. 

Sometimes the patch exhibits a tendency to enlarge by centrifugal 
growth, erythema palmare eentrifugum, vel psoriasis palmaris centrifuga, 
and presents the annulate character already referred to under the head 
of syphilitic tubercles. In the case of a centrifugal growth, the 
border is defined, the area presents the red, dry, cracked, and exfoli- 
ating character above described. The ring may be small or large, 
running out upon the fingers in one direction, and upwards upon the 
wrist in the other. As soon as it becomes stationary, a new inflam- 
matory action .may begin in the centre of the ring, and a second, 
a third, and a fourth ring may b<? formed in succession, affording a 
curious and remarkable example of cutaneous disease. 

Sometimes the ring possesses a tubercular character, and is slightly 
raised, is, in fact, an instance of the annulate tubercle in the palm of 
the hand. I have delineated a case of this kind in my Portraits of 
Diseases <>f the Skin, under the name of erythema annulatum palmare. 1 
I had not at that time detected the syphilitic nature of the affection, 
and had only seen one or two cases ; I have examined many since, 

1 Plate XIX., K. 



406 DISEASES FROM THE SYPHILITIC POISON. 

and with a slight alteration in the arrangement of the words, I think 
I may still retain the name I then gave to it, namely, erythema palmare 
annulatum. 

The erythema palmare annulatum syphiliticum differs from the 
forms previously described, by getting well in the area while the circle 
expands. The circle may remain for a long time cracked and angry, 
but the area recovers its healthy structure and appearance completely. 

In a case of erythema palmare of one hand, with syphilitic tuber- 
cles on other parts of the body, the disease of the palm was a circular 
ring, the epidermis being hard and dry, and slightly raised, and the 
area of the ring dry and cracked. The patient had several such rings 
of small size on his wrist, a half circle on the breast, and a large 
broken circle with a cluster of scattered tubercles within its area, on 
the buttock. These eruptions had been in existence for ten years ; 
that on the hand had got well and broken out repeatedly, but the 
patch on the buttock had continued from its first appearance, being 
sometimes better, and sometimes worse. 

In another case, one of erythema palmare centrifugum, 1 with a 
similar affection of the skin of the penis, the eruption occupied the 
whole of the palmar surface of the hand and fingers, extending partly 
to the back of the latter. The leading features in the appearance of 
the hand, were, a vivid redness of the entire surface, bordered by an 
abrupt margin of a deeper red than the rest ; a swollen state of the 
diseased skin, a raggedness of surface, arising from irregular exfolia- 
tion of the epidermis, and a cracked and bleeding state of the deeper 
grooves of flexion of the fingers. The cuticle had been repeatedly 
thrown off from the inflamed surface, and the centre of the palm was 
smooth, of a vivid pink color, and covered by a thin coating of newly 
formed and smooth epidermis. On other parts of the surface of the 
hand, the newly formed cuticle was in a state of exfoliation. The 
inflamed skin of the penis had resulted from the extension of two 
patches of annulate tubercle, the borders of which formed the 
boundary of the disease. The border was several lines in breadth, 
and covered by a broken layer of desquamating epidermis ; while the 
area of the patches was red, furfuraceous, and exhibited a tendency to 
crack in the direction of the' lines of motion of the skin. 

Erythema palmare syphiliticum is a syphiloderma of the second 
period, namely, that of tertiary syphilis, and is among the latest of 
the evidences of the presence of the syphilitic poison in the blood. 
In five cases, in which I npted the period intervening between the 
primary disease and the affection of "the skin of the palms of the hands, 
I found the time to be respectively, four, eight, nine, and ten years ; 
and, as an illustration of the persistence of the disease in this region, 
the same five cases gave, as the periods of existence of the disease up 
to the time of the patients coming before me, nine months, three 
yea is, six, nine, and ten years. 

Occasionally I have met with cases, and have one now before me, 
wherein the syphilitic infection is recent, dating back to a period of 

1 Portraits of Diseases of the Skin, Plate XXL, AT. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 407 

twelve months, in which simple erythema, like that which occurs in 
infants, is developed. In this case, a copper-colored redness spreads 
over the palms of the hands and palmar surface of the fingers, the 
integument is thickened, somewhat indurated, or stiffened, and cracked 
in the lines of motion ; but there is no desquamation such as happens 
in ordinary cases of psoriasis palmaris, where the affection is of many 
years' duration. These cases yield to the iodide of potash, which the 
psoriasis palmaris does not. 

Erythema 'plantar e syphiliticum, vel psoriasis plantaris syphilitica, is 
identical in its mode of origin and growth with erythema palmare 
syphiliticum ; a good example of this eruption will be found among 
the Portraits of Diseases of the Skin, Plate XXII., a v. 

Lupus erythematosus is met with as an erythematous syphilo- 
derma in old standing cases of tertiary syphilis, and in conjunction 
wifrh other forms of syphiloderma, both tubercular and ulcerative, 
thus placing its connection with the second period of syphilodermata 
beyond question. It is also met with, presenting exactly the same 
characters, where none but hereditary, or the remains of infantile 
syphilis can be present, hence I have termed it syphiloderma erythe- 
matosum hmreditarium. Thirdly, it occurs occasionally under circum- 
stances of, and with appearances involving, so much obscurity, that I 
have thought it necessary, for the present, to transfer its consideration 
to the group whose name it bears, namely, lupus. At a future time, 
I hope to be able to unravel more completely the entanglement which 
envelops this very peculiar and very troublesome and obstinate f" 



SYPHILODERMA TUBERCULOSUM. 

Second Period. 

tubercula mucosa. 

When syphilitic tubercles occur on parts of the body where there 
is naturally an increased degree of moisture, or where they are kept 
in a softened condition by morbid secretions, they are apt to assume 
a state of chronic growth. Such tuberculous growths are termed soft 
or mucous tubercles, or condylomata. Their common situation is 
the perin?eum, particularly in the female, where their growth is 
favored by the secretions of the vulva. They are also found occa- 
sionally between the greater labium and the thigh ; on the scrotum, 
between the scrotum and the thigh; around the anus, in the groins, 
in the axillae, and upon the lips. These tubercles belong to the 
period of tertiary syphilis, and are the common consequence of 
the modified syphilitic poison; appertaining in that case to the 
new group which I propose to make, under the name of syphilo- 
dermata mitigata. Mucous tubercles arc far from uncommon on the 
inside of the Labia majora, and in the neighborhood of the vulva of 
married women, where they exist for years without attracting any 
attention. In their ordinary state they are very little raised above 



408 DISEASES FROM THE SYPHILITIC POISON. 

the level of the surrounding integument, but occasionally they enlarge 
and are troublesome ; and sometimes become the seat of superficial 
ulceration. 

TUBERCULA ULCERANTIA. 

Ulceration of tubercles may be either superficial or deep ; and in 
either state it may be stationary or progressive. Ulceration is one 
of the phenomena of syphiloderma which serves especially to indicate 
the long period of existence of the poison, and is strongly diagnostic 
of the second period, or that which corresponds with tertiary syphilis. 
When the ulceration is stationary, it commences on the summit of 
the tubercle, and extending its circumference by degrees, it delves 
into the substance of the skin more or less deeply. When, however, 
it is progressive, it creeps on by the circumference, and acquires th*e 
name of serpiginous, sometimes creeping over the surface to a consi- 
derable extent. At other times the creeping and the delving action 
are combined, and the horseshoe ulcer is the result. 

The deeply ulcerated tubercles are more common than the superficial, 
and their common seat is the head and face ; but they are also met 
with on other parts of the body, as on the back and loins, the limbs, 
and the scrotum. The ulcers are more or less deep and hollow, they 
secrete an ichorous or semi-purulent fluid, and are excavated in the 
midst of a thickened, red and congested skin. Sometimes they occupy 
a patch of tubercula circumscripta, and are so numerous as to give a 
worm-eaten or honeycomb appearance to the surface of the patch. 
Sometimes a solitary tubercle is the seat of ulceration, and sometimes 
the annulate form of tubercle is attacked by the ulcerative process. 

Syphilitic ulceration has frequently a progressive and centrifugal 
action, and in most instances one side of the tubercle will be found 
more deeply ulcerated than the rest ; or the ulcer will be observed to 
increase by one side while the process of healing is slowly taking 
place on the other; this is the so-called " horseshoe ulcer," a term 
which indicates its appearance sufficiently clearly. In the horseshoe 
ulcer, the integument is much congested and thickened on the side of 
the ulceration, while on the opposite side it is uniform with the level of 
the surrounding skin. 

The centrifugal action of the ulcerative process is, perhaps, most 
remarkably shown in the superficial ulceration which sometimes 
attacks the annulate tubercle ; and the process is so rapid as to have 
obtained a designation of serpiginous. I once saw a man, partially 
bald, whose head was covered with these serpiginous wheals; they 
were coated with a thin, squamous scab, and curved around his tem- 
ples like a pair of ram's horns. In another case the circles formed a 
necklace, descending for a short distance upon the breast and back. 
This latter case is illustrated in my Portraits of Diseases of the Skin, 
Plate XXIII., a Q., under the name of psoriasis gyrata syphilitica ; 
more properly, it is a syphiloderma annulatum ulcerans, or it may be 
termed, tubercula annulata syphilitica, ulcerantia, or tubercula ulcer- 
antia scrpiginosa syphilitica ; it is the syphilide pustuleuse serpi- 
gineuse of Alibert. 



SYPHILODERMATA, OR SYPHIL.ITIC ERUPTIONS. 409 



LUPUS ULCEROSUS. 

As tertiary syphilis becomes settled in the skin, it is remarkable 
how exactly it acquires the resemblance, and assumes the character of 
lupus, until at last it becomes difficult, and sometimes impossible, to 
distinguish between them ; and a kind of lupus is generated, which 
is recognized as being the result of the syphilitic poison in its tertiary 
state. Such, in fact, is lupus ulcerosus syphiliticus. 

In lupus ulcerosus there may exist one or several tubercles grouped 
together ; the affected skin is thickened, hard, of a purplish red hue, 
and upon one or more of the tubercles a thin black crust is formed. 
If the crust be removed, a deep excavated pit, filled with unhealthy 
pus, and discharging a sanious fluid, is seen beneath it. The ulcerative 
action is very slow and gradual, lasting for months without change. 
At other times the ulcerative action is more rapid ; several of the 
pits communicate, and a large unhealthy ulcer is formed, which 
destroys the part upon which it is situated, and is followed, on getting 
well, by an indelible cicatrix, with puckering and contraction of the 
surrounding skin. When the ulcer is situated on the nose, a portion 
of that organ is destroyed, and much deformity results ; and equal 
mischief, although unaccompanied by the like deformity, may occur 
upon any part of the body. 

When a cluster of tubercles are assembled together, forming a 
patch of diseased and disorganized skin, and the surface is pei'forated 
by several deep ulcerated pits, the affection was termed lupiform 
syphilis, a name which is very characteristic. 

TUMORES GUMMATI. 

The modification of syphilis by time is one of the most curious of 
its phenomena, and, at the same time, one which enables us, by tracing 
its mutations, to recognize it in a form so very different from its 
original shape, that nothing but a process of inductive reasoning could 
determine its identity. In a gentleman who had given evidence of 
the presence of the syphilitic poison in his blood for upwards of 
twenty-five years, there are now developed, since the completion of 
this period, several round tumors (tubercula gummata) in and 
beneath the skin, which evidently originated in the same cause. The 
tumors are about the size of marbles, three or four in number, and 
hard and somewhat elastic to the touch. They are situated in the 
left forearm, two or three being to all appearance in the cellular tissue 
under the skin, and one in the skin itself. The latter is slightly red 
and tender, and looks as if it would pass into a state of ulceration. 

The peculiarity of those tumors is, the great distance of time which 
intervenes between their occurrence and the reception of the poison. 
And, in this particular, they seem to deserve a place by themselves 
under the title of " chronic syphilis ;" or, if it be preferred, tertiary 
syphilis. In their hardness they remind us of cancer, and are very 
likely to be mistaken for malignant disease. When they ulcerate, 
that process takes place very slowly, and generally on one side, while 



410 DISEASES FKOJM THE SYPHILITIC POISON. 

by the other they continue to grow ; hence the ulcer has more or less 
of a horseshoe form, and the tissues over which it has passed, heal, 
but leave an indelible cicatrix. The ulcer is slowly destructive, and 
exhibits no tendency to granulate ; sometimes it dissects out certain 
tissues with great neatness. The situation in which I have seen 
these ulcers in a state of progress, is the integument immediately in 
front of the ear ; the following is an example : A gentleman, aged 
fifty, has an ulcerated sore immediately in front of the tragus of the 
left ear. It has occupied its present position three or four years, but 
latterly has been enlarging. It is now about the size of a half-crown 
piece. On the side next the temple it is bounded by an elevated 
mound of thickened skin, into the base of which the ulcer seems to 
burrow. The ulceration has dissected out two ligamentous bands in 
front of the tragus, and has isolated them completely. It is devoid 
of granulations, gives rise to no pain, and secretes no pus. The 
surface exudes a small quantity of a transparent and colorless ichor, 
which, left to itself, dries up into a thin scab. 

Another gentleman, between fifty and sixty, has a tumor of this 
kind excavated at its base by a deep ulceration, the latter being 
covered with a slough. He has suffered from the disease sixteen 
years ; and although existing for so long a time, the ulcer now is 
scarcely larger than a shilling. It is of the horseshoe form, and has 
burrowed into the base of the hypertrophied skin constituting the 
tumor. The ulcer is situated immediately in front of the tragus. 
The skin of the temple in front of the ulcer, and, indeed, as far as the 
angle of the eye, presents the appearance of a cicatrix, and along its 
border is an impetiginous eruption, which has crept over, and is the 
cause of the cicatrized skin. In this portion of the skin, and particu- 
larly in the neighborhood of the ulcer, are a number of enlarged 
venules. 

SYPHILODERMA ULCERANS. 

Syphilitic ulcers sometimes take on a more extensive character than 
that already described ; the ulcers are large, unhealthy-looking, and 
frequently phagedenic, their edges are angry and excavated, and the 
skin around, red and indurated ; sometimes their surface is dry, some- 
times it pours forth an acrid ichorous discharge, and sometimes they 
are filled with a transparent reddish jelly-like secretion. These large 
ulcers are most frequently met with on the face, but they are also seen 
occasionally on other parts of the body. In one case I found a large 
phagedenic sore on the calf of the right leg ; a smaller sloughing sore 
near the tendo Achillis, and several cicatrices, each as large as a half- 
crown. On the left leg, near the ankle, was another unhealthy-look- 
ing sore, of considerable magnitude. The skin surrounding the sores 
was of a deep-red color, indurated, and apparently infiltrated ; the 
edges of the phagedenic sore were dry, black, and excavated perpen- 
dicularly, and the floor was covered with a gray magma. There was 
no trace of pus, and in the large sore no secretion of any kind. 



YPH1L0DERMATA, OR SYPHILITIC ERUPTIONS. 411 



SYPHILODERMATA HEREDITARIA. 

We have next to consider the modifications of syphilis in another 
point of view, namely, in its effects upon the offspring of syphilized 
parents, constituting hereditary syphilis. The transmission of the poison, 
in this instance, is indirect, passing from the father to the mother, and 
from the mother to the foetus, the mother, in this case, being a sufferer 
by the transit or wholly unaffected, being, in fact, the mere material 
of communication between the contaminated source on the one hand, 
and the newly-formed being on the other. In other cases, the mother 
may be herself the primary source of the poison, and the father quite 
free from inculpation, the case being then one of direct transmission. 
Of a similar kind is the propagation of syphilis to an infant by means 
of the milk of the nurse. Infantile syphilis is therefore not always 
hereditary ; it is transmitted when the poison is imbibed with the milk 
intended for its nutrition, and is hereditary only when it is received 
in the womb of its parent. But the difference in the two cases is not 
so considerable as might at first sight be imagined ; the poison is in 
both instances a secondary poison, modified and chastened by trans- 
mission through the blood of another. 

It is not impossible in the adult to have secondary syphilis, that is, 
constitutional syphilis, without any primary disease; I have met with 
such instances. In the transmission of the secondary poison, secondary 
disease is more frequent; thus, the newly contaminated wife, her 
husband being locally sound, is probably affected from the first with 
secondary or constitutional syphilis, and has no local disease; or, if 
there be local disease, such disease is of a secondary or tertiary nature, 
such as morbid secretion and mucous tubercles. And, in the case of 
the infant, unborn or born, it is obviously the secondary disease, or 
constitutional syphilis, which is transmitted. But we have now to 
consider the after-effects of the poison on the infant, those effects 
which correspond with the tertiary syphilis of the adult. It would 
be contrary to all analogy to suppose that infantile syphilis ceased 
with its first outbreak; that it was eliminated from the constitution 
by the remedies employed for its cure; no, it lingers in the blood; 
like syphilis acquired by the adult, it has its secondary and its tertiary 
characters; and it makes its appearance in after-life under a variety 
of forms, sometimes as a lupus, and sometimes a lepra. The direct 
connection between certain forms of lupus and syphilis cannot be doubt- 
ed by the practical observer; and the relation between syphilis and 
lepra has appeared to me, in some cases, to be equally clear. 

Hereditary syphilodermata present themselves to our notice in three 
forms, which serve to represent the three periods of the poison. The 
first period, represented by erythema, corresponds with the secondary 
syphilis of the adult; the second period is tubercular, and brings to our 
notice tubercles in different forms, and lupus non exedens and exedens, 
which correspond with the tertiary form of direct syphilis; while the 
third period belongs to a stage later than tertiary syphilis, a kind of 
quaternary gradation, and offers for our consideration another tuber- 



412 DISEASES FROM THE SYPHILITIC POISON. 

cular affection of a more permanent kind than most of the preceding, 
namely, lepra. 

SYPHILODERMA H.EREDITARIUM ERYTHEMATOSUM. 
ERYTHEMA SYPHILITICUM INFANTILE. 

Syn. Syphiloderma erythematosum marginatum. Lepra syphilitica 
infantilis. Psoriasis syphilitica infantilis. 

The more common form of manifestation of constitutional syphilis 
in infants is erythema of the hands and feet, with epidermal exfolia- 
tion; small circular and slightly elevated tubercles, with depressed 
centres (cupped tubercles), looking like lepra in process of peripheral 
extension, and without scales; erythematous patches, of various extent 
and figure, also slightly raised above the surface ; and excoriations 
and fissures around the apertures of the body, the seeming consequence 
of acrid humors. Then the disordered state of the mucous membrane 
is manifested by acrid discharges from the eyes, nose, mouth, and often 
ears ; moist excoriations at the angles of each of those apertures ; 
aphthae and congestion of the mucous membrane of the mouth and 
fauces ; a clogged state of the air-passages ; tumefaction of the mem- 
brane of the trachea and larynx ; and, not unfrequently, diarrhoea. 

Sometimes the exfoliation of the epidermis of the hands and feet 
takes place at birth, the process having commenced in the womb of 
the mother ; at other times the first symptoms of syphilis are not 
apparent for three weeks, six weeks, and even later. In an instance 
of exfoliation at the time of birth, the child, although arrived at the 
full term, was small, thin, and shrivelled, and the blood oozed out 
copiously from the denuded surface of the hands and feet; the blood 
was more diffluent than natural, and resisted all means to arrest it, and 
the child died in the course of a few days. The appearance of the 
feet and hands suggested to the accoucheur who attended the mother, 
a total absence of the skin. 

The first symptoms of the syphilitic affection were evinced in an 
infant of five weeks, otherwise plump and well-looking, by the devel- 
opment of what seemed to be a common but severe cold. Its mouth 
and lips became dry and parched ; it had cough ; and its throat and 
air-passages seemed clogged with a thick, viscid mucus. It was nearly 
in this state at the sixth week. When I saw it, the mucous membrane 
of the mouth, as far as could be seen, was congested, and spotted with 
the white films of aphthae, the voice was hoarse and husky, and the 
lips and angles of the mouth cracked and excoriated. There was a 
viscous secretion from the nose ; the child was emaciated ; and its 
skin dry. An inflamed state (erythema) of the feet was apparent at 
birth, and was followed soon after by a similar state of the hands ; the 
cuticle was thrown off in large flakes and by repeated exfoliations, 
leaving the skin beneath very tender, and giving rise to cracks, of 
various extent, in the direction of the joints. Some of the cracks 
extended quite around the fingers, were of considerable depth, and bled 
a good deal. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 413 

In another child, three months old, there appeared an extensive 
erythema covering a considerable part of the surface of the body. 
The eruption was of a dull-red hue, slightly raised above the level of 
the surrounding skin, smooth as though tumid, lustrous like metal, 
exfoliating in some situations, and distinctly circumscribed, the border 
being slightly raised, and paler than the rest of the patch, reminding 
us of the wheals of urticaria. On the nates and thighs were several 
circular spots about as large as a sixpenny-piece, very slightly raised, 
particularly at the border, and depressed, or cupped, in the centre. 

On the face the erythema was chiefly situated around the eyes, nose, 
and mouth, and on the cheeks, in the course of the tears. The eyelids 
were inflamed and swollen, the eyes moist, and there were excoriations 
at their outer angles. There were also excoriations around the aper- 
tures of the nose, and at the commissures of the mouth. The nose 
was filled with mucous secretion, and the nasal respiration snuffling; 
the cry was hoarse. On the limbs the eruption occupied chiefly the 
outer side? of the arms and legs. 1 

In a more advanced stage of the disease, the erythema having 
subsided on the feet and hands, had left behind it an exfoliation of the 
epidermis ; the head was covered with dandruff and scurf, while on 
the nates there were numerous tubercular spots of a circular figure, 
about the size of a sixpence, with raised margin and depressed or 
cupped centre, of a dull-red color, and bearing a close resemblance to 
the spots of lepra divested of their scales. The child was thin and 
weakly, its skin muddy and rough, the conjunctivae congested, and 
the eyes weeping ; there was a copious discharge from the nose, a thick, 
mucous secretion clogging the mouth and fauces, a viscous phlegm in 
the trachea, which impeded breathing, and a hoarse cry, which indi- 
cated swelling of the mucous membrane of the larynx ; the child was, 
besides, very uneasy and fractious ; had been suffering from a some- 
what severe diarrhoea, and was still relaxed in its bowels ; at the 
angles of the eyes, nose, and mouth, the mucous membrane and skin 
were excoriated, and poured out an acrid secretion ; and there were 
similar excoriations on the lips, which had produced a tender state of 
the nipples of the mother. 

SYPHILODERMA HiEREDITARIUM TUBERCULOSUM. 
LUPUS SYPHILITICUS VEL TUBERCULA LUPOIDEA. 

The commonly recognized source of lupus is scrofula ; and then we 
may ask, What is scrofula ? Now, scrofula, if not in all cases, certainly 
in some, takes its origin in syphilis. Therefore, lupus, or scrofulous 
lupus, may be considered as an appendage of syphilis, more or less 
direct. But it is not my intention to discuss an opinion which I put 
forth several years back, that scrofula was the offspring of syphilis, 
nor to interfere with those examples of undoubted lupus which I have 
already considered in a previous chapter; but simply to investigate 

1 A good example of this eruption will be found among the Portraits of Diseases of the 
Skin, Plate XVIII, A W. 



414 DISEASES FROM THE SYPHILITIC POISON. 

certain obscure forms of cutaneous disease which occupy the neutral 
ground between syphilis and lupus, which must be classed with lupus, 
if lupus be syphilis ; but, if such be not the case, must, for the time 
being, be considered as lupoid, and constitute a group of transition 
between syphilis, from which they clearly proceed, and lupus, with 
which they appear to be analogous. 

These lupoid affections originate in the syphilitic poison conveyed 
to the infant, either during its intra-uterine existence, or soon after 
birth ; and they bear the same relation to the syphilitic poison, then 
introduced, that tertiary syphilis bears to secondary syphilis proceed- 
ing from the primary poison. In a word, they may be regarded as 
syphilodermata of the second period, or as examples of tertiary cuta- 
neous eruption. 

They are doubtless modified by a variety of conditions, and to this 
circumstance may be attributed the great diversity which they exhibit 
in respect of severity, and their nearer approach to, or farther removal 
in appearance from, syphilis. Thus, we should expect a different cha- 
racter of eruption in a poison obtained from the mother, than from 
one derived from a nurse ; and the difference of period or severity 
would modify it in both of these sources. Again, the modifications 
might spring from the child itself; its powers of nutrition, its degree 
of vital energy, its diseases, particularly, those of an eruptive kind ; its 
age, for sometimes these affections appear in youth, and at other times 
may not be developed until manhood or womanhood. 

But, whatever the cause or degree of modification, the lupoid dis- 
ease may be classed, according to its pathological characters, into sim- 
ple or non ulcerating tubercles ; ulcerating tubercles, the ulcers being 
superficial or deep ; and serpiginous tubercles. 

Of the simple or non-ulcerating lupoid tubercles, the following is an 
example : A young lady, aged nineteen, had an incomplete ring of 
tubercles situated on the cheek, near the lower eyelid. The line of 
tubercles curved upwards towards the temple, where they were met 
by a wheal-like tubercle, nearly an inch in length. The color of the 
elevations was a dusky red, approaching to purple ; they were perfectly 
smooth on the surface, and had occupied their present position for 
nearly two years. She had been treated with lotions and ointments 
of all kinds, and nitric acid had been proposed to her. The fear of a 
scar resulting from the use of the caustic, and the recent appearance 
of a similar tubercle on the nose, was the occasion of her visit to me. 
She had no other spot of any kind about her. I treated her with the 
bichloride of mercury and sarsaparilla, and she gradually lost all trace 
of the eruption. It was not one of those cases of disorganization of 
the skin which I have described in connection with syphilitic tubercles, 
and therefore there was no cicatrix, not even a stain, left behind. 

Of the ulcerating lupoid tubercles, the following may be taken as an 
example : A young gentleman, under twelve years of age, was brought 
to me with a cluster of lupoid tubercles on the scalp ; some of the tuber- 
cles were in a state of ulceration, and several large cicatrices showed 
where other ulcers had healed. He was an unhealthy-looking boy, 
of short stature for his age, had large tonsils, and a tumid abdomen. 



. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 415 

His mother informed me that he had suffered from eruptions of the 
same nature as that upon the scalp, ever since his birth. The age of 
this boy precluded the possibility of his having been in the way of 
the syphilitic poison ; and yet no one who had ever seen a syphilitic 
tubercular eruption would have doubted for an instant as to the nature 
of the one under which he was suffering. I have seen several cases 
of a similar kind, which have been brought to me under the idea of 
their being an obstinate form of ringworm. A young lady and her 
brother, the children of a college friend, not remarkable for his steadi- 
ness as a student, are now under my care for this disease, and are 
progressing rapidly under the use of the iodide of potassium. 

Serpiginous lupoid tubercles. — A common form of the lupoid 
eruption is a roundish patch of a dull-red or purplish-red color, slightly 
raised above the level of the surrounding skin, indolent, sometimes 
spreading by the circumference, so as to form a ring and healing 
imperfectly in the centre; sometimes spreading on one side only, and 
healing on the rest; sometimes ulcerating deeply, in one or several 
points, in the latter case producing a worm-eaten appearance of the 
skin ; sometimes ulcerating only superficially, and forming a dark, 
irregular crust. The secretion of these patches is an unhealthy pus, 
or a mere watery ichor. This form of eruption is very commonly 
met with on the limbs and on the backs of the hands and feet ; it 
exhibits a tendency to a peripheral situation ; hence it may be deve- 
loped also on the nose or on the ears. On the limbs and hands it would 
be recognized as a scrofulous eruption ; on the nose or ears, it would 
be called lupus. In a lad at present under my care, the patch of mor- 
bid skin occupies the dorsum of the thumb, and is perforated by seve- 
ral small openings, which exude a healthy-looking pus. In a young 
man of eighteen, it affects the dorsum of the feet; by peripheric growth, 
the disease has been carried forward upon the toes, and outwards to 
the border of the foot, the central part having healed and left a per- 
manent cicatrix. The greater part of the ring has also healed, so that 
what remains is only a portion of the original disease. 

A gentleman, aged twenty-seven, has several patches of this kind on 
his right arm, the worst being on the dorsum of the hand. He has 
been several years under my care, paying me a visit from time to time. 
When he first came to me, there were numerous holes in the skin, 
which was thickened and undermined, and the disease occupied the 
middle of the back of the hand. Now, the part originally affected has 
healed, the disease has advanced upon the knuckles ; there is no longer 
any deep ulceration, but the tubercular ridge which remains is covered 
by a thick, dry crust, which brings into view an abraded surface 
when raised. The disease began as a tubercular blotch of small size on 
the skin covering the carpo-metacarpal joint of the thumb. In his 
boyhood, be suffered for a long time from chronic ophthalmia; a 
younger brother is affected with enlargement of the lymphatic glands 
of the neck, but the rest of his brothers and sisters, older than him- 
self, and five or six in number, are perfectly healthy, as are his parents. 

A young lady, twenty years of age, was brought to me, in the year 
1851, with an eruption on the dorsum of the right foot which had 



416 DISEASES FROM THE SYPHILITIC POISON. 

troubled her since infancy. She was a person of lymphatic tempera- 
ment, but otherwise enjoyed good health, and she had no other dis- 
order of the skin of any kind. The present eruption appeared on her 
foot as a patch of redness, when she was two months old, and con- 
tinued in an indolent state; at four years, an abscess formed on the 
spot, and was succeeded by ulceration, which spread by degrees over 
the dorsum of the foot, towards its outer border and the toes. The 
ulceration continued until within the last few months, but has now 
healed. As it moved onwards upon the skin, the parts behind healed, 
and formed a large and permanent cicatrix. 

At the present time, the skin along the roots of the toes is thickened 
and uneven, of a purplish-red color, soft to the touch, fissured here 
and there by deep grooves, and in some parts incrusted with small 
adherent scabs. There is no ulceration, but when the scabs peel off, 
a little moisture oozes from the skin. The entire surface is red, and 
in a state of epidermal exfoliation. On the border of the foot, the 
erythema and epidermal exfoliation cease abruptly, and the broken 
and irregular edge of the thick cuticle of the sole of the foot forms the 
boundary of the disease. 

The cure of these serpiginous ulcerations affords a good example of 
an unhealthy healing process; large red granulations are thrown up, 
which frequently become covered with epidermis, and produce a papil- 
lated and uneven surface; and irregular patches of granulations, 
sheathed with epidermis, are interspersed with small ulcerated hol- 
lows, which extend more or less deeply into the structure of the skin. 
In some instances, these granulations appear to be formed independ- 
ently of ulceration, and a large, raw, granulating or granulated sur- 
face is presented to view. These granulations bleed very easily, and 
are so soft as to be frequently torn away in the removal of the dress- 
ings. When, by peripheric growth, the ulcerative action has reached 
the toes, and extended into the clefts between them, a curious pheno- 
menon occurs. The opposite surfaces of the toes being raw and 
granulated, and the granulations lying for some time in contact, 
become adherent, and the toes are united with each other to a greater 
or less degree. In a lady at present under my care, all the toes of the 
right foot are so closely united together, that no vestige of them, as 
separate organs, exists; they form a single mass, and give the end of 
the foot the appearance of an amputated stump. 

There is another form of lupoid tubercle, which is commonly solitary, 
and is met with on the tip, or upon the aire of the nose, and chiefly in 
women. It is generally recognized as a form of lupus attended with 
hypertrophy, and differs from lupus exedens, with which alone it can 
be confounded, in the absence of the destructive activity of the latter. 
A lady, aged sixty, has Buffered from this disease more than four 
years; it began with a feeling of dryness of the mucous membrane 
within the nose. A small pimple, which formed a scab on its summit, 
then appeared upon the ala nasi ; it gave rise to no pain, but, from its 
inconvenient position, was frequently picked with the finger-nail. It 
has never exceeded a quarter of an inch in diameter, and appeared to 
be composed of a mass of imperfectly-formed granulations. Latterly, 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 417 

it seemed to shift its situation, as though it were enlarging on one 
side, and shrinking on the other ; and on examining the part which it 
had left, it was found that it had imperceptibly eaten through the 
border of the nostril. 

The term, hypertrophous, must therefore be taken to refer only to 
the general appearance of these singular growths ; they are destructive 
as well as hypertrophous, although to an infinitely less degree than 
the form of lupus which has been distinguished by the name of 
"exedens." As I have already observed, with regard to syphilitic 
tubercles, the hypertrophy of this form of lupus seems to result from 
the conversion of the normal structure of the skin into its own 
substance, a material of an inferior type of organization, which may 
be aptly compared to a vegetable fungus ; and it follows, that, as soon 
as an absorbing action is set up, either accidentally or by the aid of 
medicine, the fungous tissue vanishes, and a deep hole is left in its 
place. Hence the disappearance of these growths is always followed 
by a cicatrix, and, as I have observed in the case of the lady just 
referred to, by a permanent loss of structure. 

This form of lupus offers some variety in point of color, a variety 
which seems to depend more upon the state of health or age of the 
patient than upon anything special in the morbid structure itself; 
and partly, perhaps, also on its situation. In a peripheral region, like 
the end of the nose, the circulation is less active than in more central 
situations, diseases occurring upon it are liable to congestion, and the 
gradual conversion of arterial into venous blood gives them a purplish 
bloom, or a duskiness or lividity of hue. 

Lepra, considered as a syphiloderma, belongs to a later period 
than the preceding forms ; it is not developed, like them, in the 
individual who receives the poison, but in a succeeding generation, 
sometimes in the immediate successor of the syphilized person, and 
sometimes more remotely. In support of these views, I quote the 
following case, and am content to leave the subject to the reflection of 
the student. All that belongs to the proper history of lepra will be 
found in a previous chapter. The case to which I allude is briefly 
this: A man had infantile syphilis when a child; he married, and 
had eight children, two of whom died as infants ; of the six surviving 
children, three are the subjects of lepra vulgaris. 1 

Treatment. — In the treatment of syphilodermata, we must, in the 
first instance, subdue the feverish symptoms which accompany the 
eruption, in other words, the syphilitic fever; we must remove the 
poison from the blood by every means in our power ; and thirdly, we 
must support the powers of the system, to give it greater energy to 
eliminate the poison, and also to resist its lowering tendency. To 
remove the poison we have recourse to remedies which are calculated 
to act on the natural cmunctories of the system, the bowels, liver, 

1 "On Syphilis, constitutional and hereditary, and on Syphilitic Eruptions," by Erasmus 
Wilson, F.R.S., 1802, page 167. 

27 



418 DISEASES FROM THE SYPHILITIC POISON". 

kidneys, and skin ; and our means of support must be derived from the 
catalogue of tonic remedies, amongst which the most useful is iron. 

It rarely happens that the syphilitic fever rises so high as to 
require the abstraction of blood ; but such cases sometimes occur, and 
if the patient be full and strong, no inconvenience can arise from 
the practice. Local congestions are relieved by the bleeding ; the 
nervous system oppressed by the weight of the poison is lightened ; 
and the blood which remains is impressed with a different action to 
that of generating a morbid ferment ; namely, one of repairing its 
own loss. On the other hand, it must be borne in mind, that upon 
the general powers of the system will fall the labor of eliminating 
the poison, and resisting its morbid effects ; hence the constitution 
must not be lowered, and particularly so in cities and large towns. 
Indeed, the power which we possess of relieving the blood through 
the natural emunctories is so great, that venesection is only likely to 
be required in very severe cases of local congestion, as of the brain 
or lungs ; and, even itf such cases, the quantity requiring to be 
removed is very small. The general inflammatory excitement at- 
tendant on an outburst of the syphilitic fever is therefore to be 
combated by an active purge, by diuretics, and by diaphoretics. A 
dose of calomel and colocynth, followed by a draught of senna and 
Epsom salts, will effect the first of these objects ; and tartarized 
antimony, with abundance of diluent drinks, the rest. Opium is also 
a necessary element of the treatment, its purpose being to calm irrita- 
bility and restlessness ; with this object, and for the purpose of aiding 
the action of the mucous membranes and skin, ten grains of Dover's 
powder, at bedtime, will be found of much service. 

As soon as the inflammatory excitement is allayed, it is time to 
begin the mercurial treatment. I am not aware that any particular 
form of mercurial preparation is superior to another for this purpose. 
I select usually the protioduret, which I prescribe in doses of a third 
of a grain, in combination with extract of lettuce, or conium, three 
times a day. This medicine agrees with the stomach usually very 
well; but if it produce nausea or uneasiness, then I either exhibit 
the pills less frequently, or have recourse to some other form of 
mercurial preparation. Where the alimentary canal evinces a decided 
repugnance to the presence of mercury, we may obtain its effects by 
means of inunction. For this purpose a drachm of /the strong 
mercurial ointment should be gently rubbed into the inner side of the 
thigh and leg every night at bedtime, changing the leg each night to 
avoid too much irritation of the skin. In a case where it was of con- 
sequence that the inunction should not attract the attention of the 
patient's family, I limited the frictions to the soles and inner sides of 
the feet with perfect success. Indeed, the inunction may be made on 
any part of the body that shall be most convenient to the patient. 

In pursuing the mercurial treatment, it is of the utmost importance 
to pay attention to hygienic conditions and diet. Stimulants of all 
kinds, either in food or drink, are to be carefully avoided, as is also 
exposure to cold and fatigue. And the intention of the treatment 
should never be lost sight of, namely, to increase the natural functions 



i 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 419 

of the depurating or emunctory organs, the bowels, the liver, the 
kidneys, and the skin. The action of the mercury, and especially 
the functions of the kidneys and skin, are very much aided by the 
use of the compound decoction of sarsaparilla ; the compound decoc- 
tion of guaiacum ; the decoction of saponaria ; or the infusion of 
elder-flowers. I have no belief in the specific powers of sarsaparilla ; 
but I cannot conceive a remedy better suited for the purpose of 
soothing the alimentary canal, and at the same time of acting on the 
depurating organs, than the compound decoction of that root. For 
this purpose it must be taken largely ; a pint and a half or a quart in 
the course of the day. 

We now have the plan of treatment of syphilodermata of the first 
period, or those which depend on secondary syphilis, before us, 
namely, the careful avoidance of all stimulants, either mental or 
physical ; the patient to keep his bed or his room ; and to defend 
himself particularly from the risk of being chilled. Medicinally ; if 
the inflammatory symptoms run high, and the powers of the system 
be equal to the loss, abstraction of a few ounces of blood ; leeches or 
mustard cataplasms for local congestions; a calomel and colocynth 
purge, followed by a black draught, together with liquor ammonite 
citratis and tartarized antimony ; or effervescent salines, with anti- 
mony ; and a Dover's powder at bedtime, until the inflammatory 
stage is subdued. Thirdly, mercury in small doses, with the compound 
decoction of sarsaparilla; attention to the bowels, and an opiate, if 
necessary, at bedtime. 

Besides this, which may be regarded as embracing the more essen- 
tial points in the treatment of constitutional syphilis, there are several 
appliances which may be added to the general treatment, or be made 
to occupy a prominent position, according to the views of the surgeon 
or the convenience of the patient ; for example, the warm bath, and 
vapor bath. The former of these is soothing and agreeable, and 
may be used daily, or even twice a day. The latter might also be 
used daily ; it is a powerful and important remedy, and establishes 
an active drain, which doubtless carries off a large share of the 
syphilitic poison in its stream. The vapor bath, of late years, has 
acquired additional importance, from its having been made the chief 
agent of treatment of constitutional syphilis by Langston Parker. 
Mr. Parker raises the vapor of the bath by means of a lamp, and he 
also introduces beneath the cloak which surrounds the patient an 
oxide of mercury, furnished with a separate lamp, for the purpose of 
vaporizing it; hence, he observes, the patient is "exposed to the 
influence of three agents, heated air, common steam, and the vapor of 
mercury." Here, it will be seen, the treatment is made to turn upon 
the general emunctory property of mercury, and the special emunctory 
action of the skin. 

In Germany, in addition to several curative processes founded on 
the limitation of supply, one method of treatment, which may be 
briefly defined as a triple compound of starving, purging, and sweat- 
ing, enjoys especial favor. I mean the treatment by Zittman's decoc- 
tion. This treatment is as follows : On the first day the patient takes 



420 DISEASES FROM THE SYPHILITIC POISON. 

a full dose of calomel and the resinous extract of jalap. During the 
next four days he drinks daily two quarts of Zittman's decoction ; 
one quart of the strong decoction, taken warm in the morning, and 
one quart of the weak, cold, at mid-day. On the sixth day he repeats 
his calomel-and-jalap pills ; and during the four succeeding days 
continues the decoction as before. On the eleventh day, if the patient 
be strong, he takes another dose of the purgative pills ; if not, this is 
dispensed with. During the treatment the patient's diet is carefully 
regulated ; on the days when he takes the purgative medicine he has 
three meals of broth ; on the decoction days he is allowed two ounces 
of roast meat and two ounces of bread. He keeps his bed during the 
entire treatment, and at its conclusion is not permitted to quit his 
room for some time longer, maintaining a low diet, and drinking the 
decoction of the woods. If the patient be suffering under syphilitic 
ulcers, these are dressed, simply, with lint soaked in water ; and if he 
be weakly, he takes of Zittman's decoction only one bottle a day, 
instead of two, with a view to prolong the treatment. If he be not 
cured at the conclusion of the treatment, it is to be repeated a second 
time, or until he is well. This treatment has the sanction of a sound 
and practical surgeon, whose practice I had the advantage of following 
for some time — Chelius, of Heidelberg. 

The decoction keeps up a constant state of perspiration from the 
skin, increases the quantity of urine, and produces five or six watery 
evacuations in the course of the day. Its mode of preparation is as 
follows : 

Decodum fortior. 

R. — Sarsaparilla radicis concisse, ^iv. Sub fine coctionis admisce, 
Aqua? fontaiifp, Oxxiv. Senna? foliorum, ^iij. 

Coque per quartam bora? partem, et adde Glycyrrhiza? radicis, ^iss. 

Aluminis, Anisi seminum, 

Sacchari albi, aa ^vj. FcEniculi seminum, aa ^ss. 

Hydrargyri chloridi, giv. Decoque ad octaria xvj, 
Antimonii oxysulphureti, ^j, et cola, 

in nodulo ligato. 

Decodum tenve. 
R. — Decocti fortioris residui. Pulveris cinnamomi, 

Sarsaparilla? radicis, ^vj. Pulveris cardamomum, aa giij. 

Aqu;e fontana?, Oxxiv. Glycyrrbizse radicis, ^vj 

Coque, et sub fine coctionis adde Decoque ad octaria xvj, et cpla. 

Pulveris corticis citronum. 

After the symptoms of constitutional syphilis have fairly subsided 
under the influence of the mercurial treatment, nitric acid may be 
exhibited for two or three weeks longer, to give tone to the mucous 
membrane, and remove any remains of the poison which may still 
linger in the blood or in the tissues. The dose of the dilute nitric 
acid is twenty drops twice or three times a day, in sweetened barley- 
water; or it may be combined with the fluid extract of sarsaparilla, 
as a vehicle; or, should there be any appearance of anaemia, we must 
restore the healthy condition of the blood by means of ferruginous 
remedies. 

We may now suppose the first attack of constitutional fever, or 
secondary symptoms, to have passed away ; but it does not therefore 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 421 

follow that the syphilitic poison is entirely banished from the blood ; 
on the contrary, the probability is, that after the lapse of a few months 
a second attack will occur, and after that we may have a third, a 
fourth, and even more ; the attacks at last becoming irregular, and 
putting on a new shape and new characters. We have, therefore, to 
consider what modification of treatment may be most suitable for these 
successive attacks ; what change of remedies the chronic character of 
the syphilitic disease may require. 

It is a curious fact, that as the attacks of constitutional syphilis 
become further removed from the original contagion, that is, as the 
poison becomes more and more assimilated, mercury seems to lose its 
influence, and other remedies acquire the control of the poison which 
it previously possessed. That may not be the case with regard to the 
second, or even fhe third, outbreak of the syphilitic fever ; the time 
varies in different constitutions ; but we must be prepared for the 
manifestation of the peculiarity sooner or later. In the second attack 
of constitutional disease, the protioduret of mercury will possibly be 
found to retain all its power ; in the third, the bichloride may be more 
efficient ; in the fourth and successive attacks, the iodide of potassium. 
It is difficult to explain this peculiarity otherwise than by supposing 
that the tissues lose their susceptibility of being excited by the mercury 
after a number of repetitions. 

In syphilodermata of the second period, those forms which belong to 
the "tertiary syphilis" of Ricord, mercury is not only inadequate to 
the removal and cure of the disease, but is actually injurious, inducing 
irritability of system, producing new and more violent attacks of 
eruption, and forcing a simple tubercular eruption into a state of 
refractory ulceration. It is at this period that iodide of potassium 
takes the lead as an anti-syphilitic remedy, and its use is attended 
with the most satisfactory results. Sometimes it effects a cure in a 
short period ; at others it seems to flag in its effects, and requires to 
be increased in dose ; and it may be beneficially assisted by bitters, 
or in case of an anaamic state of the constitution, by the preparations 
of iron. I have before remarked that a useful and effective dose of 
the iodide of potassium in the beginning of treatment is three grains ; 
this we may increase, if need be, to five, eight, or ten grains, or even 
more, three times in the day; and, indeed, without such increase, we 
are liable, in cases rendered unusually rebellious by mal-treatment, 
ami especially by the abuse of mercury, to fail altogether, and attri- 
bute to the remedy what is properly due to our own mismanagement. 
The iodide of potassium is the remedy best suited to those chronic 
forme of tuberculous eruption which I have distinguished as tubercula 
circumscripta, and it is especially indicated in the ulcerating tubercles, 
ami those deeply-seated disorganizations of the skin and subcutaneous 
tissues which have received the name of "gummata." 

1 have already observed that in those chronic syphilodermata where 
mercury ceases to exert a beneficial influence; where mercury is not 
merely negative .in its effects, but obviously and plainly excites an 
irritable and 'lestructiVe action both on the system at large and upon 
the local disease ; our great remedial agent is iodide of potassium, 



422 DISEASES FROM THE SYPHILITIC POISON. 

and this medicine frequently acts as a charm in such instances. I 
have in my mind at this moment the case of a gentleman, who one 
morning staggered feebly into my consulting-room, accompanied by 
his physician, and ordinary medical attendant. He introduced him- 
self as a lost and hopeless man ; and he certainly presented a vivid pic- 
ture of exhaustion and decay. He showed me several large, deep, and 
foul ulcers upon his legs, and he said that the surgeons of eminence 
whom he had consulted, even a few days before his visit to me, would 
insist upon his taking mercury, which he knew was destroying him. 
I prescribed for him the iodide of potassium ; and in less than three 
months he called upon me, having just returned from the country, 
declaring that he had never felt stronger or better in his life. I 
should have been very sorry to have mentioned this case, if I thought 
it could, by any possibility, be used as an argument "against mercury. 
Mercury, as I have before observed, is an invaluable medicine, but 
one requiring to be used with judgment; to be watched in its effects, 
and to be regulated according to those effects rather than. upon any 
scheme of theoretical results; indeed, mercury, like iodide of potas- 
sium, and every other medicine, must be exactly graduated in dose, 
combination, and period of administration, to the special case of the 
patient. Each patient, as he varies in physiognomy from his foregoers, 
varies also in constitution, in the characters of his disease, and in his 
susceptibility to the influence of medicine. 

The iodide of potassium seems to act, generally, upon all the tissues 
of the body in a remarkably short space of time, and especially on the 
kidneys. Its combination with the compound decoction of sarsaparilla 
facilitates its action, notably increasing its diuretic properties, and sup- 
plying a convenient vehicle with which the poison may be excreted 
by the mucous membranes and by the skin. 

After it has been taken for a time, it begins to excite an overaction 
in the various tissues of the body; firstly, in the mucous membrane; 
then in the nervous system and brain; and these actions may be 
regarded as evincing the poisonous properties of the medicine. I 
have said that the symptoms now referred to are first perceived in 
the mucous membranes, and especially in that of the fauces, the nose, 
and the eyes; all that is necessary, therefore, is to watch for these 
symptoms, and, if it be thought desirable, as soon as they occur, the 
use of the remedy should be suspended, or the dose reduced. In this 
way we are enabled to put an immediate stop to the continuation of 
the morbid effects. When iodine begins to act as an irritant to the 
system, there is a feeling of stiffness and dryness in the throat; more 
or less coryza; and an uncomfortable feeling with increased secretion 
from the nose; sometimes tenderness of the salivary glands and sali- 
vation. By degrees the congestion extends to the trachea and 
bronchial tubes, adding bronchitis to the other symptoms. These 
indications of irritation of the mucous membrane generally precede 
those of disturbance of the nervous system, and give sufficient warn- 
ing of a necessity for putting a stop to the use of the medicine. 
When the iodine has been carried further, the patients complain of 
dimness of sight, giddiness, and pain in the head ; and in one patient, 



I 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 423 

I saw severe palpitations of the heart. But although I have used the 
medicine extensively, I have seen very little of its morbid effects, 
probably from always exhibiting it with caution. 

My mode of administering the iodide of potassium, is to prescribe 
five grains twice or three times a day, according to the power or con- 
stitution of the patient. If I begin with five grains three times a day, 
I increase the dose during the second week to seven grains and a half; 
and to ten grains during the third week ; always impressing on the 
patient that if any disagreeable effects are produced by the medicine 
he is to stop it immediately, and as soon as the disagreeable symptoms 
have subsided, begin it again, but in a less dose. If the cessation 
should continue for a week, I require that the dose for recommence- 
ment should be that first prescribed. In this way I get the full 
effects of the medicine rapidly, and I avoid the risk of any mischievous 
effects from its use. I was first led to adopt this mode of employing 
the iodide of potassium from meeting with cases in which the medi- 
cine had been continued for many months at the same dose, and had 
lost its effect on the constitution of the patient completely ; and 
subsequent experience has led me to believe that as much and more 
effect may be produced, by this mode of administration, in three 
weeks, than can be obtained by the unvarying dose in as many 
months; indeed, after a time, the remedy becomes utterly useless. 
Sometimes I find it convenient to continue the five-grain dose for a 
longer period than a week, and the same with the others ; I endeavor 
to ascertain the period during which the action of the medicine is 
progressive, and have the dose increased immediately that period is 
passed. *• 

Syphilitic eruptions of the skin, when general, require no other 
local treatment than the occasional use of the tepid soap-bath. When 
situated on the face, the diluted citrine ointment, or the nitric-oxide- 
of-mercury ointment, applied with gentle friction, are good remedies, 
and tend to hasten the absorption of the pimples and tubercles, and 
the removal of the stains which they leave behind them. 

When tubercles pass into a state of ulceration, these ointments are 
still of much service, as gentle stimulants ; but when a more soothing 
remedy is required, or when we merely desire to protect the ulcer 
from the influence of the atmosphere, we may have recourse to the 
benzoated ointment of oxide of zinc, either by itself, or in combina- 
tion with a few grains of camphor, or a few drops of liquor plumbi 
diacetatis. 

For sloughing sores, an opiate lotion and water-dressing answer the 
purpose well, and if the ulcers be indisposed to heal, the black wash 
and yellow wash, either with or without opium. In these cases, and 
particularly in phagedenic sores, a lotion of chloride of zinc will be 
found to be of excellent service; a medium strength is one drachm to 
the half pint, but this can be increased or diminished, according to its 
effects, and particularly in reference to the degree of pain which it 
may occasion. 

Of course the local treatment is quite secondary to that of the gene- 
ral system ; but I have succeeded beyond my expectation, in several 



424 DISEASE? FROM THE SYPHILITIC POISOX. 

instances, in causing the removal of local tubercular masses in a state 
of ulceration, by frictions with the mercurial ointment, and the appli- 
cation of a mercurial plaster. 

It is remarkable how soon the fall of the hair, which accompanies 
syphilis, is checked by means of the remedies employed for the relief 
of the other symptoms; the mercurial preparations or the compounds 
of mercury with iodine. The plan of treatment is therefore simple 
and obvious. Occasionally, however, alopecia is the only evident 
symptom of the presence of the syphilitic poison in the blood, in 
which case we should hardly be warranted in subjecting our patient 
to a mercurial course. Under such circumstances I have found the 
iodide of -potassium, in three-grain doses, three times a day, or five 
grains twice a day, answer every purpose; continuing the treatment 
in augmenting doses, for a medium period of six weeks, unless symp- 
toms of iodic irritation arise. 

For local application the best remedy is a pomatum, consisting of 
one part of the nitric-oxide of mercury ointment, to three of scented 
pomatum. This should be well rubbed into the roots of the hair at 
bedtime each night, and a proper degree of action maintained in the 
scalp, by means of plentiful friction with the hair-brush. As an aid 
to the stimulant excitation of the skin, the ammoniated hair-wash, 1 
introduced among the roots of the hair by means of a sponge, may be 
used in the morning before brushing. This wash, besides aiding in 
the excitation of the skin, assists in removing the scurf which is apt 
to form upon the sordid skin of persons affected with constitutional 
syphilis, and affords great comfort to the patient ; and it not only 
checks the fall of the hair, but causes its reproduction where it has 
already fallen. 

The chronic affections of the nails, attended with dryness and imper- 
fect formation, come into the same category with the erythematous 
affections of the palms of the hands and soles of the feet, and their 
treatment is mercurial; either the protioduret or the bichloride. It is 
quite remarkable how rapidly chronic erythemata of the hands and 
feet, attended with desiccation, cracking, and exfoliation of the cuticle, 
and depending on syphilis, give way to the action of either of the 
above preparations, in alterative doses. In three weeks the misery of 
years may frequently be entirely cured, after every other remedy and 
mode of treatment had been tried in vain. Medical men suffering 
from this complaint have been startled at my audacity, when I have 
promised them a cure, in three weeks, of that which has baffled them- 
selves for months, and more frequently for years; but my promise 
has rarely failed to be accomplished. 

I must mention, however, that these erythematous disorders are apt 
to return from time to time ; but the remedy may be repeated as often 
as they appear, and in the end will prove triumphant. I do not 
believe that any good results from continuing the medicine for many 
days beyond the period of cure ; I order it to be left off at the end of 
a week, after the skin is healed; and prefer, in case of any return, to 
resume the remedy as before. 

1 Vide, Selected Prescriptions. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 425 

For the local treatment of these erythemata, the camphor cerate is 
the best application, or the benzoated ointment of oxide of zinc with 
honey or spirit of camphor. In either case the proportion is a drachm 
to the ounce. An ointment containing a drachm of glycerine to the 
ounce of simple cerate is a good application; or a lotion containing 
one part of glycerine to three of camphor mixture or rose-water. 

The purpose of these local remedies is simply to keep the skin 
moist; and great comfort is sometimes obtained by sleeping with a 
water-dressing on the parts ; the cure is to be looked for from the in- 
ternal remedies alone. 

Onychia and the painful granulating sores which sometimes form> 
under and around the nails, also derive their cure form the constitu- 
tional treatment; but they at the same time require some local 
management. When in an inflamed state, water-dressing, with Ali- 
son's prepared lamb-skin, or a solution of opium in place of simple 
water ; when less painful, a weak solution of chloride of zinc, or 
acetate of lead, are the proper remedies. Sometimes the zinc oint- 
ment, or simple cerate with camphor, or an ointment of Peruvian 
balsam, answer better than the lotions; and in two or three instances 
I have obtained the best results from covering the granulations with 
powder of charcoal. 

Mucous tubercle, like other forms of syphilitic tubercle, obeys the 
will of the internal remedies employed against the manifestation of 
the syphilitic poison in the skin. It would get well without any 
external application; but sometimes we maybe required to treat it 
locally, when the nitrate of silver, the oxide of zinc ointment, or a 
lotion of chloride of zinc, or alum, or the black or yellow wash, will 
be found the best suited to our purpose. After drying the tubercles 
well, it has been recommended to powder them with calomel. 

For infantile syphilis the treatment must consist of mercury ; 
and the best remedies in every respect, according to my experience, 
are the bichloride, calomel, or hydrargyrum cum creta", which may be 
administered either to mother or child, or to both, according to the 
judgment of the surgeon. If the mother evince symptoms of consti- 
tutional syphilis, it may be sufficient to exhibit the mercury to her 
only, the infant drawing its nourishment from her breast being 
regarded as part of herself. If the proportion of mercury thus 
conveyed to the infant be^deemed insufficient, there can be no objec- 
tion to give it independently to the latter. And in several instances 
I have satisfied myself with giving it to the infant only. I have not, 
in iliis case, for an instant imagined that the mother was free from the 
poison, but only that her tissues were so far accustomed to its presence, 
that it was incapable of setting up any morbid action, at least so long 
as she continued to suckle, and the milk performed the office of an 
emunctory current ; and I was quite prepared, should any retardation 
in the cure of the infant occur, to exhibit the remedy to the mother 
also. In a word, T consider the safest practice in these cases to be, to 
give mercury to the mother as well as to the infant ; taking care to 
moderate the dose to such a degree as not to check or injure the 
secretion of milk. 



426 DISEASES FROM THE SYPHILITIC POISON. 

I have heard it suggested that the infant may be affected with 
syphilis in the womb of its mother, without the latter being contami- 
nated; and that contamination of the mother may subsequently occur 
in consequence of transmission of the poison from the diseased child 
to the tissues of the parent. Such a theory I consider to be most 
unphilosophical ; it is easy to comprehend that, in the instance of 
syphilitic contagion, the child may be the seat of manifestation of the 
disease, just as in a male the disease may fix upon one spot or one 
organ of the entire body ; indeed, not merely because the foetus under 
such cicumstances is a part of the whole, but because it is also a part 
of more recent formation, a new organ, and made up of new tissues, 
which we may conceive to be more susceptible of receiving, and more 
easily influenced by, a morbid poison. 

It is also perfectly consistent with physiological laws, that the foetus 
having become the focus of excessive accumulation of the poison, the 
latter may react upon the parent with such force as to cause a mani- 
festation of the presence of the poison in her tissues as well. The 
problem, therefore, resolves itself simply into one of latency and 
development. 

The dose of the bichloride to the mother under the above circum- 
stances should be one-sixteenth of a grain, in combination with syrup 
of poppies and tincture of bark, or the compound fluid extract of 
sarsaparilla, three times a day; and to the infant one-twenty-fourth of 
a grain in syrup of poppies and dill-water. 

The local treatment for excoriations around the nose and mouth of 
the infant is the benzoated ointment of oxide of zinc, or an ointment 
composed of a drachm of the unguentum hydrargyri nitratis to the 
ounce of ceratum cetacei. The latter is especially applicable to exco- 
riations in the neighborhood of the eyelids. For cracks upon the 
hands and feet, and for excoriations around the pudendum and anus, 
the benzoated ointment of oxide of zinc is also the proper application; 
and secretions in these parts, may be absorbed by the oxide of zinc 
powder. For discharges from the meatuses of the ears, soap and 
water is the best remedy. 

Hereditary syphilis. — After the age of infancy, congenital syphi- 
lis gradually merges into what may be termed hereditary syphilis. 
The infantile syphilis gets well, but several months or years after- 
wards, it breaks out again. Sometimes, Jiowever, the patient has 
been free from any indications of syphilis in his infantile age, the first 
manifestations of its presence in the system being delayed to the 
period of advanced childhood, puberty, or even adult life. This more 
properly constitutes hereditary syphilis. The kind of syphilitic 
disease now under consideration, in its more recent forms, yields 
without much difficulty to the bichloride of mercury ; when more 
advanced, the iodide of potassium is a useful auxiliary ; and in a 
more distant remove, the combinations of iodine, mercury, and arsenic, 
and cod-liver oil, become valuable remedies. I have had little ex- 
perience of the hydrochloride of gold ; but I should apprehend 
that it is to the present form of syphilis that it would be especially 
applicable. 



SYPHILODERMATA, OR SYPHILITIC ERUPTIONS. 427 

Some of the forms of hereditary syphilis are remarkable for their 
extreme obstinacy, refusing the slightest obedience to medical agents, 
and maintaining their course unimpeded. These cases are only to be 
managed by opposing obstinacy to obstinacy, by following them up 
with appropriate remedies, that is, with remedies directed upon a 
proper principle, when even the most enduring will be found to yield 
at last. In pursuing this course, it is evident that we must seek to 
obtain a gentle and continuous influence over the system, such as that 
by which Nature conducts her operations ; we give expression to our 
meaning by the term, " alterative ;" our process should be essentially 
alterative ; large doses of medicine and heroic action are only calcu 
lated to exhaust the powers and do mischief. In making these 
observations, I have now in my memory several persevering " incur- 
ables," who, by a steady continuance of remedies for periods varying 
between one year and four, are fast approaching cure. And in another 
point of view, these observations are not without their value; the 
patient frequently tires, the surgeon despairs ; in both instances, be- 
cause an unwarrantable expectation has been created ; but if, from the 
first, the difficulty be appreciated, both move onward with more 
comfort, and with less prospect of disappointment. The surgeon is 
no longer incited to make a bold effort, which cannot but end un- 
happily, and the patient takes no step to urge him to such an attempt 
by impatient suggestions. 

In some instances of the lupoid tubercle, I have found the iodide 
of potassium a serviceable remedy ; in others, the bichloride of 
mercury has proved most useful. Sometimes the iodide of iron has 
brought about a healthy condition of the general system, which has 
been followed by an improvement in the local disease ; and, at other 
times, I have derived the best results from the triple solution of mer- 
cury, iodine, and arsenic, given alone, or in conjunction with cod-liver 
oil. When the arsenic, in the triple compound, has appeared to be 
objectionable, I have had recourse to the tonic properties of quinine 
as an adjunct to the iodide of mercury, and with a very satisfactory 
resuk. The following formula is an excellent substitute for Dono- 
van's solution, agreeing well with the stomach, and possessing the ad- 
vantage of being in a more condensed and convenient shape for deglu- 
tition : 

R. — Hydrargyri biniodidi, gr. J. 
Qui rise iodidi, gr. j. 
Micae panis, gr. j. 
Mucilaginis, q. s. 

In these very obstinate cases, it is important to remember, that 
when the remedies disagree with the patient, or seem to cease to exert 
a beneficial action, they should be immediately suspended, and re- 
sumed after such an interval of time as may seem good in the 
judgment of the surgeon. Like food and hygienic conditions, medi- 
cines, which are very beneficial at one moment, lose their power after 
a time, and then require to be changed or modified, either in form or 
quantity, until the appetite for them returns. This is a very neces- 
sary rule to be borne in mind in the management of so obstinate a 
class of diseases as those of the skin. 



428 DISEASES FROM UNKNOWN ANIMAL POISONS. 

For the treatment of lupus and lepra, I must refer my readers to 
the special essays on those subjects in a previous chapter ; and for 
further illustrations of my views on the treatment of constitutional 
syphilis, to my work on that subject. 



CHAPTER XV. 

DISEASES ARISING FROM ANIMAL POISONS OF UNKNOWN 
ORIGIN, AND GIVING RISE TO ERUPTIVE FEVERS. 

The diseases assembled under this group are the exanthematous, 
or eruptive fevers ; the poisons from which they originate are the 
rubeolous, scarlatinous, and variolous ; and the manifestations of these 
poisons are as follows : 

Rubeola, Variola, 

Scarlatina, Varicella, 

Vaccinia. 

These eruptions are characterized by fever of greater or less 
severity, which precedes and accompanies the exanthem ; by an ex- 
anthem, or inflammatory congestion of the derma, which makes its 
appearance in the form of red points, and pursues a specific course ; 
and by their mode of termination, namely, in resolution and desqua- 
mation of the epidermis in the first two, and by exudation and 
incrustation in the variolous affections ; while all are liable to terminate 
by delitescence. 

Taking this view of the exanthematous diseases, I conceive myself 
warranted in placing the variolous affections in a group with which 
all their analogies harmonize. They correspond accurately with the 
definition given above ; the premonitory symptoms present a xdose 
resemblance to those of rubeola and scarlatina ; the eruption is iden- 
tical at its first appearance ; and the general management required is 
the same. At a later period, when variola assumes the pustular form, 
it must be regarded, as far as pathology is concerned, in the light of 
an advanced stage of rubeola and scarlatina, or as a severe type of the 
latter diseases expending its violence on the skin, instead of retro- 
grading on the mucous membranes. At the present day we should 
not hesitate to admit the variolous diseases to a place among the ex- 
anthematous fevers, nor to remove them from the unpathological 
position which they occupy among the Pustulge and Vesiculse °f 
Willan's classification, 

The severity of the febrile symptoms of exanthematous diseases is 
determined primarily by the nature and activity of the exciting 
cause of the disease, by the state of constitution of the person affected, 
and by the greater or less freedom of evolution of the morbific action 
upon the tegumentary textures. Secondly, it is modified by the extent 



ERUPTIVE FEVERS. 429 

and severity of the exanthem, or, in other words, by the reaction of 
the eifects upon the system. The constitutional symptoms are also 
much paodified by the extent of surface diseased. When that surface 
is great, as is necessarily the case, where, not merely the dermal layer, 
but the whole mucous membrane of the body is affected, the peri- 
pheral and sentient parts of a considerable proportion of the nerves of 
the body are involved in the inflammatory disorder, and, as a conse- 
quence, the spinal and cerebral symptoms reach their highest pitch of 
severity and danger. 

The congestion of the superficial capillary vessels which accom- 
panies the exanthematous fevers is not limited to the dermal tissue 
alone, but is distributed more or less completely over the tegumentary 
surface of the entire body, including the mucous membranes. From 
the great susceptibility of the latter, they are generally the first affected, 
as we perceive to be the case in the angina of scarlatina, and the catarrh 
and conjunctivitis of rubeola. But there is this difference between 
the inflammation of the cutaneous surface and that of the mucous mem- 
brane : in the former, the inflammation either invades the entire sur- 
face at once, or runs regularly and more or less rapidly over it ; but 
in the mucous membranes, the different parts are affected irregularly 
and in succession, while some escape altogether. Thus, in scarlatina, 
the mucous membrane of the fauces is first invaded, then possibly that 
of the lungs, while, perhaps, at the close of the disease, when a favor- 
able convalescence is expected, the inflammation may be transferred to 
the alimentary canal, or kidneys, and prove fatal by exciting an un- 
controllable diarrhoea or anasarca. The same remarks apply to 
rubeola ; for after the violence of the cutaneous efflorescence has passed 
away, there is much to be apprehended from secondary inflammation 
of the mucous membranes. 

The immediate seat of the inflammatory congestion of the exan- 
themata is the vascular rete of the derma, and the difference of tint 
observable in these diseases at their height and during their decline, 
is sufficiently explained by reference to the structure and normal phe- 
nomena of the skin. When the degree of excitation of the cutaneous 
nerves is small, and the arterial determination but little exalted above 
the ordinary standard, the vascular rete of the derma is only partially 
congested, and the redness produced by this congestion is slight ; when, 
however, the nervous activity is aroused to its highest pitch of energy, 
as in scarlatina, the congestion is intense, and the bright scarlet of the 
arterial blood coursing through its vessels is little obscured by the 
tli in veil of epidermis which holds it in its sphere. The congestion in 
rubeola, scarlatina, and variola, is not confined to the horizontal strata 
of the vascular rete of the derma, but implicates also the vertical rete 
of the follicles, and in that manner gives rise to the punctiform and 
papillar appearance of the redness which is characteristic of these 
eruptions. 

The cresccntic, or, rather, the imperfectly circular, form of the con- 
gested patches seen in rubeola, depends upon a peculiarity in the dis- 
tribution of the cutaneous nerves and vessels, and corresponds with 
that natural appearance of the skin, which is so frequently seen in 



430 DISEASES FROM UNKNOWN ANIMAL POISONS. 

healthv children, and which is denominated mottled. Again, I have 
observed, that, in injecting the limb of an infant with size and ver- 
milion, I can imitate all the forms of redness seen in the exanthe- 
matous diseases, by ceasing to inject from time to time, or by filling 
the capillaries to their uttermost. 

The decline of congestion of the derma is accompanied by certain 
alterations in the tint of redness which betokens its presence. Thus 
the red patches are observed to lose their vivid brightness, to become 
duller in their hue, and to pass through various shades of purple, until 
they become bluish and livid. These changes depend upon the degree 
of excitement of the cutaneous nerves at the several periods indicated 
by alteration in the color of the exanthem. When the nervous energy 
is at its highest point, the capillaries contract actively upon their con- 
tents, and maintain a rapid current of arterial blood through their 
channels, but, as the nervous excitement becomes gradually allayed, 
the capillaries lose their power to contract, and become distended by 
the full stream that moves more and more tardily onwards in its course, 
giving time for the arterial current to combine with the carbon of the 
tissues through which it flows, and be converted into venous blood. 

The above phenomena will explain, also, the differences of color 
which the exanthem may assume at an earlier period than its decline, 
and even from the commencement of its appearance, as, for instance, 
in scarlatina maligna, or more strikingly, in rubeola nigra. The first 
step or motive influence by which this change is effected, is depression 
of nervous power ; this depression, depriving the capillaries of their 
tonicity, or, in other words, of their means of resisting the pressure of 
the arterial current, they yield, they become dilated, and from capil- 
laries, which they were, they are converted into a venous plexus, 
through which the blood moves feebly and slowly, gathering carbon 
in its tardy course. 

Congestion of the capillary rete of the derma necessarily gives rise 
to tumefaction, the extent of swelling being, to a certain degree, the 
measure of the increased quantity of blood distributed through the 
part. Hence it is obvious that all exanthematous patches must be 
raised above the level of the surrounding skin, even although 'the 
degree of tumefaction be really very slight. 

Another cause of tumefaction in an inflamed and congested tissue 
also follows as a natural consequence from the over-distension of its 
vessels. I have endeavored to show that the nervous excitation of 
the part must have diminished before over-distension of the capillary 
vessels can take place, but, as soon as that change has ensued, another 
phenomenon is immediately developed, namely, transudation of the 
watery part of the blood into the surrounding textures, thereby 
physically relieving the congested vessels of their overload of fluid. 
The fluid which is thus transuded through the coats of the vessels is 
serum, containing in solution more or less of fibrin ; and the seat of 
transudation, for the most part, the subcutaneous cellular tissue, where 
it gives rise to oedema. I may instance scarlatina in some cases as a 
particular illustration of this kind of tumefaction, although it will be 
found, upon close observation, to be much more extensively present 



ERUPTIVE FEVERS. 431 

among the exanthemata. This important phenomenon is not con- 
fined to the dermal tissue ; it occurs also in the mucous membrane, 
and sometimes with fatal consequences, as, for instance, in the 
laryngitis of scarlatina and rubeola, where it is apt to induce oedema 
of the glottis. 

As the present group of diseases are infectious and contagious, it 
may be well to inquire the precise meaning which we attach to these 
terms. In their more usual acceptation, the terms infection and 
contagion relate to modes of transmission of a poisonous principle. 
When the transmission is effected by a material substance, and is 
brought about by actual contact, the term contagion (immediate con- 
tagion) is employed; but when transmission is effected through the 
agency of the winds, and at a distance, the mode of communication is 
designated infection (mediate contagion). In other words, when the 
poisonous principle is volatile, and capable of diffusion in the atmos- 
phere, it is infectious; but when this diffusibility is absent, it is simply 
contagious. The difference between infection and contagion is, con- 
sequently, more apparent than real, and some of our most able 
writers use one or other of the terms to imply transmission, without 
reference to its mode. Thus, it is observed by Dr. Watson, "Since, 
in all cases, the disease is conveyed to the person of the recipient by 
particles of matter proceeding from the person of the sick, and since 
it seems very unimportant whether those particles are in a solid or in 
a gaseous form, whether they are imparted by direct contact of the 
two human bodies, or by being wafted through the air, or carried 
upon articles of clothing, I shall include both and all these modes of 
communication under the simple term, contagion. This, in fact, 
is what is done in common discourse : all disorders that are catching, 
I shall take leave to consider contagious." 1 

In whatever way the poisonous principle be brought to the body 
of a sound person, and with whatever part of his body it come in 
contact, whether with the cutaneous surface, with or without abrasion, 
as in contagion, or with both the cutaneous and mucous surface in 
infection, the mode of its reception by the system is the same. In 
the first instance, it is dissolved in the fluids of the body ; and, in 
the second place, is conveyed by imbibition into the circulating 
current of the blood, thence to act on the nervous system, and alter 
its functions. Once introduced into the system, the poisonous princi- 
ple possesses the remarkable power of exciting an action similar to 
that which existed in the body whence it emanated, the intention of 
tli.it action being the reproduction of an identical poison. Liebig 
has compared this process to fermentation ; as, when a particle of 
yea.3t is brought into contact with a fermentable fluid, the particle 
of yeast is itself lost, or is too insignificant to be traced further ; but 
the action which it excites occasions the formation of an abundance of 
similar yenst. 

In certain diseases regarded as contagious, another mode of trans- 
mission occurs ; the principle of cantagion exists in the form of germs 

1 Lectures on the Principles and Practice of Physic. First edition, p. 655. 



132 DISEASES FROM UNKNOWN ANIMAL POISONS. 

or seeds of a parasitical organism, which, wafted to a soil fitted for 
their nutrition, become developed, and assume an active growth. Of 
this kind are the parasitic fungi found upon the surface of the bodies 
of animals, and, according to some, the mycoderma of the crusts of 
favus. Langenbeck found fungi in the body of a man who died of 
typhus fever. Owen has seen them coating the internal surface of. 
vomica} in the lungs of the flamingo; and similar observations have 
been made by other observers. 

The most interesting, as it is the most important of the phenomena 
of morbid poisons, is the modification which they produce in the 
system of the affected person. By virtue of this modification, the 
susceptibility to be excited by a similar stimulus, or to take on a 
similar action, is deteriorated, and, in many instances, entirely 
abolished. We might recur again to the simile suggested by Liebig, 
for we are incapable of again exciting fermentation in a fluid that 
has already fermented. It is upon this important principle that 
safety from a repetition of attacks of eruptive fever reposes ; although 
the cause is somewhat different in the two cases ; for in the one, the 
material of fermentation is exhausted; while, in the other, the 
ferment is assimilated, and the blood therefore rendered insensible to 
its presence. 



RUBEOLA. 

Syn. Measles. Morbilli, Ali-abbas. Blactim, Ingrassias. Rubeola?, 
Sauvages. Rosalia. Phcenicismus. Rougeole, Fran. Die Maseru, 
Kindspecken, Germ. 

Rubeola, or measles, is an acute inflammation of the tegumentary 
investment of the entire body, both cutaneous and mucous, associated 
with fever of an infectious and contagious kind. 

Upon the skin it is characterized by a patchy redness, which, on 
close examination, is found to be produced by numberless minute 
red points and pimples, aggregated into small patches of a crescentic 
and annular form. The efflorescence makes its appearance on the 
fourth day from the commencement of febrile symptoms, increases for 
another four days, and is succeeded at its decline by furfuraceous 
desquamation of the epidermis. 

Rubeola usually attacks children and young persons, but may 
occur at any period of life ; infants and adults, however, are but little 
Busceptible of its influence. Its effects have been observed in the 
foetus at birth (Iliidanus), where the mother has suffered from the 
disease during pregnancy. The period of incubation of the contagion 
varies from seven to fourteen days, and the same individual maybe 
affected more than once. Its punctated and papillated appearance 
depends upon the state of congestion of the vascular rete of the folli- 
cles, and the semilunar form of the patches, upon some unexplained 
peculiarity in the structure of the derma, probably having reference to 
the distribution of the cutaneous nerves. The mottled aspect of the 
skin of children in health and exposed to the cold, has the same 



ERUPTIVE FEVERS. 433 

semilunar tracery, and an analogous state may be produced artificially 
by incomplete injection with size and vermilion. 

The varieties of rubeola are four in number, namely : 

Rubeola vulgaris, Rubeola sine exanthemate, 

" sine catarrho, " nigra. 



RUBEOLA VULGARIS. 

Common Measles. Morbilli benigni ; eretlirici. 

In rubeola vulgaris, the ordinary form of measles, the disease sets 
in with the usual symptoms of fever, namely, with chills, succeeded 
by burning heat, listlessness, languor, drowsiness, pains in the head, 
in the back, and in the limbs ; frequent pulse ; soreness of the throat, 
white tongue, with red edges and tip ; thirst, anorexia, nausea, vomit- 
ing, frequent dry cough, and high-colored urine. These symptoms 
increase in violence during the first four days. On the third the 
conjunctivae look red and inflamed, there is intolerance of light, and 
the eyelids are congested and swollen, while a profuse secretion of 
lachrymal fluid distils from the eyes, constituting coryza. The mucous 
membrane of the nose also pours forth a large quantity of watery 
secretion, and the irritation of this membrane gives rise to frequent 
sneezing. Inflammation of the mucous membrane of the larynx, 
trachea, and bronchial tubes, is indicated by hoarseness, impeded 
respiration, constriction and pain in the chest, and violent cough. 
Moreover, children are affected occasionally with spasm of the muscu- 
lar system and convulsions, the consequence of reflex action of the 
spinal nerves ; these spasmodic attacks are especially frequent where 
rubeola is complicated by dentition. 

The cutaneous efflorescence of rubeola makes its appearance on the 
fourth day, and is attended with heat and itching ; in children with a 
delicate skin, it appears occasionally on the. third; and, in some 
instances, from exposure to cold, or deficient susceptibility of the skin, 
on the fifth or sixth. It is first perceived on the forehead and front 
of the neck, next on the cheeks, and around the nose and mouth :' 
and if the interior of the latter cavity be inspected, it may be seen 
jvjthsimihir characters to those e xhibited on the surface of the body, | 
upon the mucous me2rbfane of the fauces and pharynx. By the fifth 
lay the clllori sccncc on the face reaches its height; it then appears 
upon the trunk of the body and upper extremities, and on the 
succeeding day upon the lower extremities. On the sixth day the 
rash upon the body and limbs reaches its height. The backs of the 
hands are the parts last affected, the rash appearing on them not 
before the sixth day, and sometimes as late as the seventh. 

The efflorescence of rubeola, when closely examined, is seen to 
consist of innumerable punctiform dots and minute pimples, aggre- 
gated into small circular patches, which, by their increase or 
coalescence, assume an irregularly crescentic figure. The patches are 
slightly raised above the surface, and the entire skin is somewhat 
swollen. The color of the rash at its acme is a bright raspberry red; 
on the eighth day it presents a yellowish-red tint, and then gradually 



434 DISEASES FROM UNKNOWN ANIMAL POISONS. 

fades to the normal color of the skin. The pimples are most fre- 
quently found mingled with the efflorescence on the exposed parts of 
the body, as upon the face and hands, and this is particularly the case 
in infants and adults. Occasionally miliary vesicles are observed to 
complicate the rash, and in a case recorded by Willan, inoculation 
with the lymph of these vesicles was found to produce a perfect 
attack of rubeola, which was communicated by infection to several 
other children. 

The decline of the efflorescence takes place in the same order as its 
invasion, fading on the sixth day upon the face ; on the seventh 
day upon the trunk and limbs ; and on the eighth day upon the backs 
of the hands. On the ninth day the form of the patches is discover- 
able only by the presence of a pale yellowish discoloration, which 
slowly disappears. To these changes, a furfuraceous desquamation 
succeeds, which is attended with considerable itching. 

Of the constitutional symptoms, some are relieved on the outbreak 
of the efflorescence, while others are aggravated. Thus the nausea 
and sickness subside on the fourth day, the restlessness and sense of 
oppression disappear on the sixth day, while the coryza, the catarrh, 
the hoarseness, and the cough, with the frequency of the pulse, decline 
on the seventh day. At about the ninth or tenth day, the resolution 
of the congestion of the intestinal mucous membrane is indicated by 
diarrhoea of some days' continuance. In the Archives Grenerales de 
3Iidecine is mentioned the case of a child who became dumb in con- 
sequence of retrocession of measles. The power of speech, however, 
returned at the end of two years. The recital of this case is accom- 
panied by another, in which a dumb child was restored to speech by 
a severe rubeola. 

It has been already remarked, that the mucous membrane of the 
eyes and pharynx is visibly affected with the rash. Other symptoms 
which occasionally develop themselves during the progress of rubeola, 
indicate a state of congestion of the internal mucous membrane. 
Thus, in some cases, there is hemorrhage from the nose ; in others, 
from the air-passages ; and in females, not unfrequently from the 
uterus. Whenever the rash is checked in its course by cold or other 
causes, the constitutional symptoms are aggravated and dangerous, the 
congestion of the mucous membranes is greatly heightened, the 
tongue becomes brown and dry, and the patient delirious. 

Although rubeola, when it runs its course regularly, is by no means 
a dangerous disease, yet, at its close, it is occasionally attended with 
severe and alarming sequelae, which call for the most vigilant atten- 
tion on the part of the medical practitioner. Thus the cough, after the 
subsidence of the rash, may return with increased force and frequency, 
be accompanied by a quickened pulse, impeded respiration, and 
symptoms of hectic fever, and lead to a fatal issue, by effusion into 
the lungs and chest, or by the development of scrofulous tubercles. 
Children are sometimes seized with difficulty of breathing, from 
swelling of the mucous membrane of the air-passages and larynx, and 
die, unless relieved by tracheotom'y, in the course of a few hours. 
The conjunctivitis, which was symptomatic of the disease during its 



ERUPTIVE FEVERS. 435 

progress, may continue in a chronic form, and give rise to ulceration 
of the eyelids. The inflammation of the pituitary membrane of the 
nose may merge into the chronic form, and pour out a purulent secre- 
tion. The mucous membrane of the mouth and fauces in infants may 
develop aphthae and troublesome ulcerations ; and in children of riper 
years, tumefaction of the lips and ulceration of the angles of the 
mouth. The salivary glands may become enlarged by the propaga- 
tion of the inflammation along their excretory ducts. In some instances, 
abscesses resulting in fistulous ulcers have been formed in these 
glands. The diarrhoea, which usually ceases spontaneously after the 
lapse of a few days from the disappearance of the efflorescence, may 
continue uncontrollable for several weeks, and issue fatally from ulce- 
ration of the mucous membrane. The mucous membrane of the vulva 
may participate in the inflammation, become ulcerated, even slough, 
and give rise to occlusion of the aperture, as occurred in a little girl 
operated on by Mr. Ferguson. 1 The lymphatic system may sympa- 
thize in the effects of the cutaneous irritation, and occasion enlarge- 
ment of the glands, which sometimes form abscesses and ulcers, or, 
where the mesenteric glands are affected, the little patient may be de- 
stroyed by interference with the current of the chyle. In other in- 
stances, secondary affections of the skin are developed, in the form of 
vesicles, pustules, and furuncles. When these cutaneous eruptions ap- 
pear during the violence of the mucous irritation, the visceral disease 
is considerably relieved, and the recovery favorable. 

Measles are most prevalent, and the accompanying catarrh most se- 
vere during the Avinter, and particularly during the first three months 
of the year. On the other hand, in the summer season, and during 
the warm weather, the disease, when it occurs, is mild and subdued. 

"In measles, which are considered by Schb'nlein as the most highly- 
developed form of catarrhal disease occurring in the northern hemis- 
phere, the urine changes with the varying stages of the disorder. In 
most cases, it more or less resembles the inflammatory type, it is red 
(as in inflammatory measles), acid, and sometimes jumentous (turbid), 
as in gastric measles, or deposits a mucous sediment during the course 
of the morning (as in catarrhal measles). Becquerel states, as the 
result of his observations, that the urine is generally inflammatory at 
the commencement of the febrile period. It becomes very dark, and 
of high specific gravity, and frequently deposits a sediment of uric 
acid ; a small quantity of albumen was found in a few of the cases. 
During the eruptive period, the character of the urine changes; if the 
eruption is slight, and there is not much fever, it resumes the normal 
type ; if the contrary is the case, the urine retains the inflammatory 
appearance. Becquerel did not meet with any case in which the urine 
was turbid or sedimentary towards the close of the eruptive stage. 

" During the period of desquamation and of convalescence, the urine 
either returns ;it once to the normal state, or continues turbid and 
sedimentary for some time, or becomes pale, clear, and anaemic. In 

1 Lancet, vol. ii. 1S50, p. 578. 



436 DISEASE.- FROM UNKNOWN ANIMAL POISONS. 

three cases, anasarca came on during convalescence, but the urine did 
not contain albumen." 1 

RUBEOLA SINE CATARRHO. 
This form of measles is perfectly identical with rubeola vulgaris, 
with the exception of the catarrhal and febrile symptoms, which are 
either exceedingly mild or wholly absent. The efflorescence is pre- 
cisely similar, and follows the same stages. Rubeola sine catarrho is 
usually observed during the prevalence of an epidemic of measles, 
when some children will be found to be attacked by the milder 
variety, while the greater number are seized with the disease in its 
ordinary form. It is not unfrequently met with in one member of a 
family, when the rest of the children have the more severe disease; 
and this is especially the case where a number of children are con- 
gregated together, as in a public school. Rubeola without catarrh 
is sometimes the immediate precursor of rubeola vulgaris, and 
children affected by this form are more liable to a second attack of 
measles than those who have experienced an attack of the ordinary 
kind. 

RUBEOLA SINE EXANTHEMATE. 

As measles* may occur, divested of their mucous inflammation, 
constituting the previous variety, so, in more rare instances, the febrile 
symptoms and mucous inflammation may be developed, with only a 
partial efflorescence, or, according to some authors, with no cutaneous 
affection whatever. Rubeola sine exanthemate, when it exists, is 
observed under the same circumstances with those in which the 
previous variety appears, namely, as isolated cases, occurring during 
the progress of an epidemic, among the members of a family affected 
with measles, or in a large assemblage of children. Sydenham refers 
to this form of disease under the name of febris morbillosa, and 
Gregory contributes additional testimony to its existence. " Guer- 
sent," says Rayer, 2 "has observed some individuals in families where 
measles prevailed, exhibiting all the other symptoms of the disease, 
except the eruption. I have myself several times seen cases of 
measles in which the eruption was incomplete, and which might have 
been referred to the morbillary fever of Sydenham; but I have never 
met with any instances like those mentioned by De Haen, Gregory, 
and Guersent, although my attention has been turned to these some 
years past." 

RUBEOLA NIGRA. 

Rubeola maligna. Black measles. 

In a debilitated state of the system, the cutaneous capillaries become 
over-distended, and the circulation through them retarded, while 
some portion of their contents is effused into the surrounding tissues. 

1 Simons Chemistry, vol. ii. p. 269. 

2 'Treatise on Diseases of the Skin,*' translated by Dr. Willis, p. 145. 



ERUPTIVE FEVERS. 437 

This condition of the vessels gives to the efflorescence a purplish and 
livid appearance, with which a tint of yellow is intermingled, and, in 
certain situations, a variable number of small spots, bearing a close 
resemblance to petechise. This form of measles is rare, and has been 
described by Willan under the designation of rubeola nigra. It com- 
mences with all the characters of rubeola vulgaris, and runs the usual 
course until about the seventh or eighth day. At this period the 
pulse becomes quickened, there is great lassitude, with prostration of 
the vital powers, and the appearance of the rash alters to the 
purplish and livid hue above noted. Sometimes the constitutional 
symptoms put on a more sevei'e character, the respiration is quick 
and impeded, the cough troublesome ; the digestive organs much 
disturbed, with parched mouth and nausea ; probably delirium and 
effusion into the serous cavities, with oedema of the cellular tissue. 
With these aggravated symptoms, the disease is likely to terminate 
fatally. Rayer remarks that he has " seen various examples of these 
livid measles in children laboring under tubercles of the lungs and 
chronic cteco-colitis, and who were exhausted by diarrhoea and hectic 
fever." 

Rayer has also remarked a variety of "black or hemorrhagic" 
measles, which are unconnected with constitutional debility, and 
characterized by a vinous-colored efflorescence not disappearing under 
pressure with the finger. He met with this form in strong individuals, 
and he finds a transition to such a modification in the greater depth 
of color, and non-disappearance under pressure of some of the patches 
in an ordinary case of rubeola vulgaris. 

Diagnosis. — The diagnostic characters of rubeola are, firstly, the 
affection of the mucous membrane, as indicated by redness of con- 
junctivae, coryza, catarrh, sneezing, sore throat, and cough, by which 
the disease may be distinguished, even before the appearance of efflo- 
rescence ; and, secondly, the crescentic and annular patches of the 
rash, with intermediate unaffected portions of the skin. 

From scarlatina it is distinguished by the crescentic patches ; the 
crimson or raspberry-like hue of the redness, and the presence of 
coryza, catarrh, and sneezing. 

In roseola, although the rash is so similar as to have obtained for 
it the name of false measles, the accompanying fever and inflammation 
are so extremely slight as to suggest a doubt of its being measles. 

The minute spots by which the efflorescence of rubeola first makes 
its appearance are like those of variola, especially on the face and 
forehead, where they are slightly papular; but upon the trunk and 
limbs this difference is generally apparent between them, namely, that 
in measles lie red points are mere spots, while in variola they are 
distinctly elevated papulae. 

The ((nigh of rubeola is at first dry and harsh; at a later period 
expectoration ensues, the expectorated mucus presenting some pe- 
culiarities which arc deserving of notice. Rayer describes these 
appearances as follows: "At first mucilaginous, clear, and limpid; 
at the end of three; or four days the expectoration becomes thick, 
rounded into pellets, smooth on the surface, of a greenish-yellow 



438 DISEASES FROM UNKNOWN ANIMAL POISONS. 

color, remaining perfectly distinct from each other, and swimming 
in a large quantity of ropy and transparent mucus, similar to 
the matter coughed up by some phthisical patients. By-and-by this 
form of expectoration is changed for another which adheres to the 
bottom of the vessel, and seems composed of a grayish homogeneous 
mucus, mixed with air and saliva, and very similar to the ordinary 
matter expectorated during chronic catarrhal affections. In young 
people the expectoration is wanting, or not at all abundant ; and many 
cases of measles occur in older subjects, without being attended with 
expectoration." Chomel remarks the following difference between the 
nummular expectoration of rubeola and phthisis, namely,. that in the 
former the nummuli swim in a transparent fluid, and in the latter in 
one which is opaque. 

Causes. — Rubeola seems to have originated in Arabia, the birth- 
place of variola and scarlatina, and to have extended with them to 
Europe and the rest of the world. It was first described by Rhazes. 
The most remarkable epidemics of measles which have occurred' in 
this country are those of London in 1671, 1674, 1763, and 1768, 
having Sydenham for their historian ; and the epidemic of Plymouth 
in 1741, recorded by Huxham. 

Measles are the consequence of a special infection or contagion ; 
under-the influence of which conjoined with a favorable state of the 
spstem, rubeola is developed. In many cases the disease is sporadic 
or epidemic in its eruption, in others it is communicated by contagion. 
The experiments of numerous authors have shown that the exant.hem 
may be transmitted by inoculating a sound person, either with the 
blood, with the fluid of the- accidental vesicles which sometimes com- 
plicate the rash, or with the secretions of those affected with the disease. 

Measles may occur at any period of life, but are most frequent in 
children. The disease is more universally contagious than any of the 
exanthematous fevers, but is only partially protective of the consti- 
tution ; for instances are by no means rare, in which the same indi- 
vidual has been affected more than once. The most obvious condition 
influencing the attack of rubeola, is inflammation of any of the mucous 
membranes, such as catarrh, cough, &c. This, indeed, constitutes a 
morbillous constitution, and the disease is most prevalent at the period 
when such a constitution is most likely to exist, namely, during the 
early months of the year. Successive epidemics of measles are usually 
characterized by some peculiarity, either in the intensity of the dis- 
ease, or variety in the affection of especial organs. 

Patients affected with measles must be secluded from those who are 
sound, in order to protect the latter against contagion. The period 
for the maintenance of seclusion is not rightly determined, but for the 
sake of security should be prolonged to at least three weeks. 

Prognosis. — Rubeola may generally be regarded as a mild disease, 
particularly when it runs its course regularly, when the symptoms of 
inflammation of the mucous membranes are not severe, and the season 
temperate. The circumstances which are calculated to render it serious 
are, irregularity in its course ; its occurrence during dentition, preg- 
nancy, after parturition, or in persons suffering for some time pre- 



ERUPTIVE FEVERS. 439 

viously- from chronic disorder of an internal organ, particularly the 
lungs ; retrocession of the cutaneous eruption ; acute affection of the 
viscera, as of the lungs, the alimentary canal, &c, or severe secondary 
disorder. Rubeola nigra is dangerous only when complicated with 
excessive debility, or with any of the unfavorable conditions above 
specified. 

Treatment. — When the disease is mild and regular in its course, 
milk diet, subacid diluents, a moderate and equable temperature of the 
sick-chamber, quiet and rest, with some simple mucilaginous drink to 
ease the cough, will be all the treatment required. Indeed, the less 
the patient be interfered with . by the employment of medicines, the 
better. 

If the febrile symptoms run high, effervescent salines, saline ape- 
rients and diaphoretics, such as the citrate of potash, liquor ammonise, 
acetatis, with or without spiritus getheris nitrici, ipecacuanha, and cam- 
phor mixture, may be employed ; but active purgatives are calculated 
to be injurious, either by determining a retrocession of the eruption, 
or by exciting a diarrhoea not easily to be checked. Moreover, it 
must be borne in mind, that diarrhoea occurring at about the ninth 
or tenth day, is a natural consequence of the resolution of the fever. 
When from any cause the occurrence of the diarrhoea is protracted 
beyond its proper period, it may be admonished by a gentle purgative. 
An emetic at the commencement of the attack is approved by many 
practitioners, and is often useful. 

When the cough is violent, the respiration frequent and difficult, 
with pains in the chest denoting inflammation of the lungs, abstraction 
of blood must be resorted to. In children, weakly adults, or old per- 
sons, leeches to the chest, or cupping in this region, will be sufficient. 
In persons of stronger habit, general bleeding from the arm may be 
found necessary. In the country, many patients will bear venesection 
with advantage, while in crowded towns or cities, this remedy must 
be employed with circumspection. As an auxiliary to bleeding, or as 
a representative when the system may be too weakly for its use, coun- 
ter-irritation by blisters or stimulant liniments, will be found beneficial, 
and both remedies will be assisted by ipecacuanha or tartarized anti- 
mony. Opiates are available only after the violence of the febrile 
symptoms has subsided, and then they may be advantageously com- 
bined with a diaphoretic, as in Dover's powder. 

Cold affusion has been recommended in measles, but has not gained 
friends, on account of the susceptibility to congestion of the mucous 
membrane of the respiratory apparatus. When, however, the skin 
is hot and dry, and so long as it continues so, sponging with cold 
water, or with vinegar and water, may be adopted with safety and 
comfort to the patient. 

Should the efflorescence recede suddenly, and some internal organ 
become affected, blood must be withdrawn from the region of such 
organ, and the rash recalled by means of a mustard-bath and the ap- 
plication of a blister. 

{ _ The j unmonia-treatment, so valuable in scarlatina, is equally appli- 
cable to~~rubeola, and may be regarded as specific in this affection as 



440 



DISEASES FROM UNKNOWN ANIMAL POISONS. 



well as in scarlatina. The details of the treatment will be found under 
the head of "Treatment of Scarlatina." Dr. Charles Witt, in his 
pamphlet on this subject, mentions the case of five boys of one family 
attacked with rubeola ; four were treated with ammonia and one with- 
out ; the four former made a perfect cure ; the latter, although origi- 
nally the strongest, was weakly in health for two years after his 
recovery. Dr. Witt's treatment consisted in the administration of a 
mild dose of jalap ; and subsequently five grains of sesquicarbonate of 
ammonia dissolved in water, every three hours, beginning one hour 
after the aperient dose. In a few hours the cough ceased, and the 
efflorescence broke out. After four d,ays the disorder declined ; for 
the two following days the ammonia Avas given every six hours, and 
on the seventh day was no longer necessary. The diet of the patients 
was beef-tea and veal broth. In a case of rubeola in the adult, pre- 
ceded by intense headache, ten grains of ammonia in solution were 
given every two hours ; after the third dose the pain ceased, the patient 
fell into a comfortable sleep, and awoke with an abundant efflorescence 
covering the skin. 

Rubeola nigra requires no other treatment in addition to that above 
recommended, unless especial indications present themselves, in which 
case the latter must be managed according to the common principles 
of therapeutics ; thus, for debility, tonics, mineral acids, &c, must be 
administered. 

The sequelae of rubeola call for a treatment especially directed to 
the nature of the secondary affection. For the cough and pulmonary 
affection, counter-irritants externally, with diaphoretic salines and 
ipecacuanha internally, are best suited. Where spee'dy dissolution is 
threatened from swelling and oedema of the mucous membrane of the 
trachea and larynx, and where the local abstraction of blood by leeches 
has failed to afford relief, tracheotomy must be performed. Chronic 
conjunctivitis and ulceration of the eyelids are best treated by the 
application of blisters behind the ears, or upon the nape of the neck, 
with a weak solution of nitrate of silver, or a collyrium of sulphate of 
zinc and opium to the parts affected ; anointing the borders of the lids 
at bedtime with simple cerate, to prevent their adhesion during the 
night. The same plan of management is adapted to the removal of 
unpleasant secretions from the ears, with the addition, in chronic cases, 
of an injection of a weak solution of chloride of lime. Aphthous vesica- 
tions and ulceration of the mouth and fauces require astringent and acid 
gargles, or brushing by means of a sponge with a weak solution of nitrate 
of silver. In children, too young to employ these remedies, a linctus 
containing the biborate of soda may be found sufficient. Ulceration 
around the mouth will speedily yield to nitrate of silver, or a solution 
of chloride of lime. When the salivary glands are enlarged, and 
threaten to suppurate, this termination may generally be prevented 
by the application of a small blister over the tumefied organ, or by 
blistering the surface with the nitrate of silver. The diarrhoea may be 
permitted to continue, unless it be prolonged for too long a time, and 
occasion debility and constitutional irritation. When such an event 
is anticipated, the best treatment will be found to be, the application 



ERUPTIVE FEVERS. 441 

of a blister on the abdomen ; frictions of the legs, with a stimulating 
liniment ; mercury with chalk or rhubarb and magnesia, internally, 
in the first instance, succeeded by chalk mixture, and the usual means 
for checking diarrhoea. When the lymphatic glandular system is 
affected, the liniment of croton oil, rubbed on the integument covering 
the enlarged glands, will be found of great service. Indeed, any treat- 
ment for the relief of the sequelae of measles will be inefficient, unless 
it be accompanied by counter-irritation. It is upon this principle that 
the secondary eruptive affections of the skin are found to conduce so 
materially to the cure of the internal disorder. These eruptive affec- 
tions are therefore not to be repelled, without establishing in the first 
instance a more manageable form of counter-irritation, such as an open 
blister, &c, in which case the eruptions will gradually disappear. 

During convalescence, the patient should be protected from pulmo- 
nary affections by warm apparel, and avoidance of a cold and damp 
atmosphere. 

SCARLATINA. 

Syn. Scarlet Fever. Febris scarlatina. Morbilli confiuentes. Rubeola 
rossalia. Scarlatine, Fran. Scliarlaclifieber, ScharlachaufscJilag, 
Germ. 

Scarlatina is an acute inflammation of the tegumentary investment 
of the entire body, both cutaneous and mucous, associated with fever 
of an infectious and contagious kind. It commences with fever 
which invades^ at an indefinite period between the second and the 
tenth day 1 after exposure to infection or contagion. On the second 
day of the fever, the eruption is developed in the form of minute 
points and papulae, which constitute patches of large size, or a general 
efflorescence of a vivid scarlet color. The rash terminates at the end 
of six or seven days, leaving the skin rough and harsh, and the epi- 
dermis peeling off in furfurse and thin laminae. 

The varieties of scarlatina, which are merely modifications in degree 
of one typical affection, are four in number, namely : 

Scarlatina simplex, Scarlatina maligna, 

" anginosa, " sine exanthemate. 

SCARLATINA SIMPLEX. 

Scarlatina benigna; erethrica. Scarlatina sine angina. 2 

Scarlatina simplex, the most benign form of scarlet fever, com- 
mences with a feeling of languor and lassitude, with pains in the 
head, in the back, and in the limbs ; with drowsiness, nausea, and 
rigors, these being succeeded by heat, thirst, and the usual symptoms 
of pyrexia, and increasing towards evening. Upon the breaking out 
of the efflorescence, the pulse is quick, but feeble; the patient is 

1 An exceptional case is reported by Dr. Duncome, of tlie Bahamas, wherein the poison 
remained Intent for eleven weeks. 
* Dr. Robert Williams. 



442 DISEASES FROM UNKNOWN ANIMAL POISONS. 

anxious, depressed in spirits, agitated, restless, and sometimes deli- 
rious. The eyes are red and humid, but without lachrymation ; the 
face is swollen ; the tongue covered in the middle with white mucus, 
is studded with congested papillae of a vivid red color, and red along 
the edges ; the tonsils are enlarged, and the palate and pharynx red. 
There is a frequent dry cough, a troublesome tingling and itching 
sensation of the skin, and swelling of the hands and feet. Sometimes, 
however, it happens that the eruption of scarlatina occurs without 
pain or febrile symptoms. 

On the second day from the commencement of these symptoms, 
the efflorescence appears upon the face, neck, and breast, in the form 
of minute points, which become aggregated into patches of irregular 
form and size. By the third day, the rash has extended to the trunk 
of the body and upper extremities, and to the mucous membrane of 
the eyes, nose, mouth, pharynx, and air-passages ; and by the fourth 
day, to the lower extremities. The patch-like distribution of the 
eruption is its normal character upon the trunk of the body. On the 
face, the neck, and upon the limbs, it speedily becomes continuous 
and diffused. The skin is hot and itching, and fully distended by the 
congestion of its vessels. The scarlet surface is sometimes uniform 
and smooth {scarlatina plana vel levigata), at other times, and in some 
situations, it is dotted with elevated points of a deeper tint than the 
adjoining surface, and is rough and granular to the touch [scarlatina 
papulosa vel milliformis), and occasionally, though rarely, it is accom- 
panied by the development of serous vesicles [scarlatina vesicularis, 
vel plilyctcenosa, vel pustule- so). The efflorescence attains its most vivid 
redness upon the evening of the third or fourth day after its com- 
mencement. It is always brighter in the evening than in the morn- 
ing, and in certain parts of the body, as upon the loins, the nates, and 
flexures of the joints, than upon the rest of the surface. 

The decline of scarlatina commences on the fifth day from the 
eruption ; the redness diminishes on those parts first, where it first 
appeared ; islets of skin of a natural hue begin to be apparent in the 
midst of the redness, and epidermal desquamation occurs upon the 
face and neck. On the sixth day the efflorescence has still further 
decreased, and on the seventh has nearly disappeared. On the eighth 
and ninth days the desquamation of the epidermis has become gene- 
ral, and, in many parts, laminae of considerable size are thrown off. 
The resolution of scarlatina is sometimes accompanied by a sudden 
and temporary renewal of the rash, preceded by a febrile paroxysm. 

" In all the acute exanthemata the urine very frequently presents," 
as Schbnlein remarks, " a peculiar character, which is due, in many 
cases, to an admixture of the bile-pigment; it has a dark-brown 
color, and resembles badly fermented beer in appearance. At the 
commencement of the crisis the urine becomes clearer, and forms a 
pulverulent sediment, consisting of uric acid (and, perhaps, urate of 
ammonia). 

"In scarlatina, the urine, at the commencement, while there is 
considerable fever, is of a deep dark-red color, and possesses all the 
properties of inflammatory urine. 



ERUPTIVE FEVERS. 443 

" In children the urine is always less colored than in adults, and its 
color, in this disease, is proportionately less dark. 

"It almost always has an acid reaction, and only exhibits a tendency 
to become rapidly ammoniacal when the disease is associated with a 
nervous or septic condition of the system. Any sediments that may 
be formed, consist, for the most part, of urate of ammonia and uric 
acid, mixed with a greater or less quantity of mucus; blood-corpus- 
cles are occasionally noticed. When the urine is ammoniacal, viscid 
whitish sediments of the earthy phosphates are deposited, and if there 
is much gastric disturbance the urine becomes jumentous (turbid). 
Albumen is commonly but not always found in the urine during the 
period of desquamation. Dropsy may even supervene without the 
urine becoming albuminous; it is sometimes preceded by the occur- 
rence of haernaturia." 1 

Simon further observes, in reference to the contradictory opinions 
put forth with regard to the presence of albumen in the urine : " We 
have dropsical symptoms with albuminuria, dropsical symptoms 
without albuminuria, and albuminuria without dropsical symptoms." 
Solon found albumen in the urine in twenty-two out of twenty-three 
cases of scarlatina. On the other hand, Philipp 2 observed, in Berlin, 
where scarlatina was recently very prevalent and anasarca could not 
be warded off, at least sixty cases in which the urine was tested both 
with heat and nitric acid, and no trace of albumen could be detected. 
Simon remarked that a desquamation of the mucous membrane was 
ascertained by the presence of numerous epithelial cells in the sedi- 
ment, a condition which frequently preceded the desquamation of the 
epidermis. 

SCARLATINA ANGINOSA. 

Scarlatina mitior. 3 Angina scarlatinosa. 

Scarlatina anginosa is a modification of simple scarlatina, and is 
especially characterized by severity of the inflammation of the mucous 
membrane of the fauces and pharynx, and by swelling and ulceration 
of the soft palate and tonsils. 

The primary symptoms of this variety of scarlatina are identical 
with those of the simpler form of the disease, but more violent. The 
fauces, from the commencement, and often before the invasion of the 
symptoms, are redder than natural. There is rapidly increasing 
sense of constriction about the throat, and a stiffness of the muscles 
of the neck and jaw. Upon the second day of the febrile symptoms, 
the throat feels rough, the voice is hoarse, there is a collection of 
viscous mucus in the fauces, and deglutition is painful and difficult. 
On tin; third and fourth days the redness of the fauces has increased, 
the mucous membrane looks turgid and swollen, and is studded with 
patches of false membrane and superficial ulcerations. The uvula 
and tonsils are so much enlarged as nearly to block up the isthmus 
fauciuni, and the tongue is coated with white mucus, and appears set 

1 Simon, Animal Chemistry. 2 Casper's Wochenschrift, 1840, No. 35. 

3 Dr. Robert Williams. 



444 DISEASES FROM UNKNOWN ANIMAL POISONS. 

with red gems, from the congestion and elongation of its papillae. 
While the local affection is thus rapidly progressing, the constitu- 
tional symptoms are indicative of serious and dangerous disturbance. 
There is nausea with vomiting, quickened respiration, a quick and 
feeble pulse, great languor and restlessness, headache, delirium, and 
excessive heat of skin, 104° or 105°. Heberden observed the tem- 
perature of the surface, as indicated by the thermometer, to be] 12 
degrees of Fahrenheit. 

When ulceration of the mucous membrane of the fauces occurs, the 
inflamed surface is seen to be studded on the second or third day, 
with a number of white patches, around which the congested vessels 
form a zone of deep red. From the fifth to the tenth day the whitish 
patch or false membrane is thrown off, and leaves a small superficial 
ulcer, which quickly heals. Ulceration takes place chiefly in irritable 
constitutions, and at certain seasons of the year, as, for instance, dur- 
ing the autumnal and winter months. 

The cutaneous eruption in scarlatina anginosa is retarded by the 
severity of the affection of the mucous membane, and of the constitu- 
tional symptoms. It fails to appear until the third day, and is then 
only partial in its efflorescence. Upon the trunk of the body it forms 
scattered patches of variable size, while upon the limbs it is developed 
chiefly around the joints. It endures longer than the eruption of 
scarlatina simplex, and the desquamation which ensues upon its 
decline is less regular and extensive. Occasionally the rash disap- 
pears suddenly the day after its eruption, to return in a day or two. 
This occurrence takes place more frequently in the autumn and winter 
season than during the rest of the year, and is either fatal in its con- 
sequences, or an aggravation of the constitutional severity of the 
disease. 

The decline of the eruption takes place on the fifth or sixth day, 
and at the same time the severity of the inflammation of the fauces 
subsides, the sloughs are thrown off, and the ulcerations begin to 
heal. The latter process, however, and the disappearance of the 
congestion of the mucous membrane are not accomplished before the 
fifteenth or twentieth day. When the throat and fauces only begin 
to be affected at the height of the rash, or even at its decline, the 
dispersion of the inflammation is postponed till a later period. The 
constitutional symptoms follow in the train of the affection of the 
throat. 

SCARLATINA MALIGNA. 

Scarlatina gravior ; l torpida ; nervosa ; .putrida ; septica. 

Scarlatina maligna is a highly aggravated form of scarlatina angi- 
nosa, occurring in persons of debilitated constitution, principally in 
the winter months of the year, and in damp, unhealthy and ill-venti- 
lated situations. Sometimes it makes its attack sporadically, while at 
other times it invades suddenly and unexpectedly during the progress 
of scarlatina simplex or anginosa. 

1 Dr. Robert Williams. 



ERUPTIVE FEVERS. 445 

The chief characteristics of scarlatina maligna are the extreme 
prostration of the powers of the system, the absence of swelling of the 
tonsils, and the extensive and deep sloughing ulceration of the fauces. 
The pulse in this affection is irregular, and scarcely perceptible ; 
there is great restlessness, deafness, delirium, and coma. The eyes 
look red and sunken, there is an acrid secretion from the nose, which 
produces soreness and excoriation around the nostrils. The cheeks 
are swollen and aphthous. The lips, the teeth, and the tongue, are 
covered by a dark-brown or black fur. The tongue is enlarged 
and tender, or even ulcerated, and the tonsils are deeply ulcerated, 
and covered with dark-colored sloughs. Respiration is impeded, 
quick and rattling ; there is a quantity of viscous phlegm in the 
pharynx ; the breath is fetid ; deglutition painful and difficult ; 
there is stiffness of the muscles of the jaws, diarrhoea, and sometimes 
hematuria. 

The eruption in this form of scarlatina is late in appearance ; it is 
pale and indistinct, with the exception of a few patches of irregular 
size, which speedily become dark and livid, and mingled with 
petechia. " Their whole skin," writes Dr. Sims, 1 " instead of the 
scarlet, assumed a very remarkable appearance, which resembled 
nothing so much as that of a dead body which has been kept several 
days, or as if a mixture of blood and water were universally diffused 
under it, and could be seen through it." The duration of the rash 
is equally uncertain with its period of invasion. " In some instances 
the rash suddenly disappears a few hours after it is formed, and 
comes out again after the expiration of a week, continuing two or 
three days ; in one case numerous patches of it appeared a third time 
on the seventh day from the second eruption, then remained for two 
days." 

Scarlatina maligna is an extremely fatal disease, as may be inferred 
from the severity of its symptoms. Some patients are cut off at an 
early period, namely on the second, third, or fourth day, while others 
withstand its violence for a longer period. Those who perish early 
exhibit appearances of extensive ulceration in the fauces, larynx, 
trachea, lungs, or in the oesophagus and alimentary canal, after death. 
The great fatality of this disease may be inferred from the observation 
of Willan, that " in 1786-87 more than two-thirds of those who were 
affected with the scarlatina maligna died between the seventh and 
nineteenth day of the fever." 

SCARLATINA SINE EXANTHEMATB. 

Scarlatina sine eruptione. 2 

During the progress of an epidemic of scarlatina, some few cases 
have been occasionally observed, in which the fever and angina were 
present, but without any, or with a scarcely perceptible efflorescence. 
Such an instance once fell under my own notice, in a weakly child, 
who slept in the same apartment with three of his brothers and sisters, 

1 Memoirs of the Medical Society of London. * Dr. Robert Williams. 



446 DISEASES FROM UNKNOWN ANIMAL POISONS. 

suffering from the ordinary attack of scarlatina simplex. This form 
of the disease is more frequent in a secondary attack, before the 
health has become completely re-established, than as a sporadic 
variety, and is more likely to occur in the adult than in children. 

ACCIDENTAL MODIFICATIONS OF SCARLATINA. 

When so extensive a surface of the body is affected as that which is 
the subject of disease in scarlatina, it is natural to expect that many 
modifications may arise from circumstances apparently trivial, such 
as those which are referable to age, constitution, season, &c. Thus, 
while, on the one hand, cases may occur in which all the constitutional 
symptoms are present without the efflorescence, on the other hand, the 
very L--e verse of this may happen. Dr. Sims remarks : " In one child 
the scarlet fever appeared without any angina, and, having finished 
its course, left the patient seemingly in perfect health ; but in a few 
days the fever returned without any eruption, but with a very consi- 
derable degree of sore throat, and much pain and swelling of the ton- 
sils and parotids, which likewise ran its course, as if the former symp- 
toms had never appeared." The same author observes, that during 
the periods of the year which are unfavorable for scarlatina, namely, 
in autumn and winter, " a frequent, short, hacking cough took place in 
several patients," without expectoration ; that this symptom was most 
severe where the cutaneous eruption and affection of the throat were 
the slightest. " Another circumstance, in the months of November 
and December,, was, that a few days after the apparent change of the 
disorder, a swelling attacked the face, but more frequently the extre- 
mities, attended with the most excruciating pain." "Some first com- 
plained of a violent toothache ; after two or three days they complained 
of an equally violent pain in the back, the first one gradually subsid- 
ing. In a day or two more, or even sooner, the pain attacked their 
elbows, wrists, and hands, which were usually the parts last attacked." 

Dr. Watson 1 and Dr. Corrigan 2 have pointed out an occasional variety 
of scarlatina anginosa, in which there is great and rapid swelling under 
the angles of the jaw, without a corresponding inflammation of the 
fauces. The patient suffers much from pressure upon the cervical 
vessels and nerves, and the cellular tissue frequently passes into the 
state of sloughing. At the outset of the swelling Dr. Corrigan found 
a few leeches of service ; but he warns us against their use, if the 
inflammation be fairly established, and he especially indicates the 
danger of incisions. 

SEQUELAE OF SCARLATINA. 

The development of the exanthema, upon certain parts of the body, 
is always accompanied by more or less oedema of the subcutaneous 
cellular tissue. In the majority of cases this oedema is removed by 
absorption of the serous effusion at the decline of the eruption, but 
occasionally it terminates in ulceration or mortification. " Two 

1 Lectures on the Practiced Physic. 2 Clinical Lectures. 



ERUPTIVE FEVERS. 447 

instances of this tendency to mortification occurred in two children 
lately admitted into St. Thomas's Hospital. In one, the whole of the 
toes of the right foot had sloughed off, and the integuments of the leg 
had mortified from the knee to the foot. In the other, mortification 
of the upper lip had commenced, and continued to spread till nearly 
one-half of the face was eaten away. The former patient recovered, 
the latter died. This tendency to mortification is common to many 
parts of the body. Dr. Watson, in his account of the fever that pre- 
vailed in the London Foundling Hospital, gives one case that died of 
mortification of the rectum, and also six others that died sphacelated 
in various parts of the body. In the girls, some had the pudendal 
region mortified; tAvo had ulcers of the mouth and cheek, which 
sphacelated externally; while one had the gums and jaw-bone so cor- 
roded, that most of the teeth fell out before she died. The lips and 
mouth of many also that recovered, were ulcerated, and continued so 
for a long time." 1 

In other cases, at the close of scarlatina, and during convalescence, 
namely, during the period intervening between the tenth and twentieth 
day, and sometimes as early as the fifth or sixth day, anasarca is 
developed. This sequela, which is referable to the transfer of inflam- 
matory action to the structure of the kidneys, is indicated by languor, 
headache, restlessness, and symptoms of general constitutional dis- 
turbance; to these succeed oedema of the face and lower extremities, 
and, in a short space of time, of the entire body. Subsequently, effu- 
sions, frequently containing urea, take place into the serous cavities, 
and the case becomes serious. The urine is deficient in quantity, of 
that peculiar smoky color which indicates the presence of albumen, 
and is frequently colored by the presence of blood, the consequence 
of impeded circulation in the kidney and rupture of the capillaries of 
the Malpighian bodies, or turbid, and deposits a whitish sediment. 
Anasarca is usually regarded as a consequence of exposure to cold 
and damp, during the progress of scarlatina, or at too early a period 
after convalescence ; but it may also result from any cause capable of 
arresting or diverting the natural course of the disorder; in other 
words, of preventing the elimination of the animal poison, which is the 
ice of the disease. Hence an imperfect or checked eruption is the 
common precursor of anasarca, or it may occur after the subsidence of 
the cutaneous efflorescence, when an undue amount of poison still 
remains in the blood, and an excess of duty is forced upon the kid- 
neys, the latter organs being already weakened by congestion, imper- 
fect circulation, and accumulation of epithelium, and possibly, of fibrin- 
ous cylinders in their tubular structure. 

Anasarca sometimes proceeds from another cause than inflammation 
and congestion of the structure of the kidneys, namely, from anaemia.. 
This happens in children naturally weakly and pallid, and is less serious 
than the inflammatory form. It may occur as early as the fourth day 
of the eruption, or at any later period; the features in this case are 
contracted and pallid, the tongue and lips bleached, and the skin pale; 

1 Elements of Medicine. By Robert Williams, M.D. Vol. i. p. 127. 



448 DISEASES FROM UNKNOWN ANIMAL POISONS. 

there is little or no fever ; the urine is pale, often neutral from the pre- 
sence of phosphatic salts, and contains neither albumen, blood-cor- 
puscles, nor epithelial cells. The cause of the dropsy in this instance 
appears to be defect of fibrin in the blood, and want of power to ex- 
crete the urea. The oedema begins in the vicinity of the joints. 

Besides the preceding, inflammation and effusion of serum and pus 
may take place into the joints. The mucous membranes also suffer; the 
inflammation of the conjunctiva sometimes becomes chronic, and lasts 
for a considerable time. Inflammation of the mucous lining of the 
tympanum and Eustachian tube may terminate in deafness, and that 
of the meatus auditorius in chronic suppuration. Occasionally ulce- 
rations are formed around the nose and mouth ; thickening of the 
upper lip may also occur ; aphthae of the tongue and mouth, or inflam- 
mation of the salivary glands. When parotiditis ensues in the adult, 
it is apt to produce considerable swelling of the gland, which con- 
tinues for a long period ; in children inflammation of this gland, and 
of the submaxillary glands, may give rise to asphyxia, or terminate 
in suppuration and abscess. Other sequelae of scarlatina anginosa are, 
chronic enlargement of the lymphatic glands of the neck, swelling of 
the testes, chronic bronchitis, chronic diarrhoea, &c, and, according to 
Dr. Scot Alison, 1 pericarditis. 

In scarlatina maligna the sequelae are severe and dangerous, and 
often prove fatal after the secondary stages of the fever have subsided. 
To the tertiary affections above detailed may be added, as occasionally 
following in the train of scarlatina maligna, ulceration of the mucous 
membrane • of the larynx, trachea, and oesophagus ; ulceration of the 
mucous membrane of the intestines, protracted cough, dyspnoea, sup- 
puration of the salivary glands, enlargement and suppuration of the 
lymphatic glands of the neck, sloughing of the nates, and hectic fever. 

Diagnosis. — The especial diagnostic characters of scarlatina are, 
firstly, the decided and acute affection of the fauces ; secondly, the early 
appearance (2d day) and rapid extension of the efflorescence; and 
thirdly,- the bright scarlet and diffused character of the rash, and its 
frequent interspersion with red papulae. 

Between scarlatina and rubeola the closest analogy undoubtedly 
subsists, and when the natural characters of the two affections are con- 
sidered, the analogy approaches almost to identity; thus both are 
inflammations of the tegumentary surface of the body, internal and 
external; both are accompanied by a cutaneous efflorescence, involving 
the vascular rete of the derma; both are liable to be succeeded by 
serious affections of the viscera, into the structure of which mucous 
membrane enters as a constituent part; both appear during the pre- 
valence of the same epidemic, engendered apparently by the same in- 
fection ; one may follow on the other as a consecutive disorder ; both 
are infectious, and both are contagious. In practice alone is it neces- 
sary to distinguish between these exanthemata. We will, therefore, 
inquire what are the distinctions which we are enabled to establish be- 
tween them. 

1 Medical Gazette, 1845. 



ERUPTIVE FEVERS. 



449 



Scarlatina. 

1. Precursory symptoms of one day's dura- 
tion. 

2. Mucous membrane of the eyes, nose, 
and fauces, red and inflamed, without secre- 
tion ; pain and soreness of throat ; no cough ; 
no expectoration. 

3. Eruption on the second day of the 
fever ; invades the entire surface of the 
body in three days; disappears by the end 
of the seventh day. 

4. The efflorescence occurs in large ir- 
regular patches, or is more or less generally 
diffused ; is of a bright scarlet, compared 
by Willan to a "boiled lobster's shell," and 
frequently interspersed with numerous 
small red papulae. 

5. Odor resembling old cheese, 

6. Principal sequela? : anasarca, inflam- 
mation of joints, gangrene, chronic bron- 
chitis, ulceration of fauces, conjunctivitis, 
otitis, abscess of salivary glands, chronic 
diarrhoea. 

7. Exfoliation of the epidermis in la- 
mines. 

8. Less infectious and contagious than 
measles. 

9. Rarely attacks the same person more 
than once. 



Rubeola. 

1. Precursory symptoms of three days' 
duration. 

2. Mucous membrane of the eyes, nose, 
and fauces, red and inflamed, with increased 
secretion, coryza, sneezing; dry cough at 
first, subsequently expectoration. 

3. Eruption on the fourth day of the fever ; 
occupies three days in "invading the entire 
surface of the body ; disappears by the end 
of the eighth day. 

4. The efflorescence* occurs in small cre- 
scentic and annular patches, with inter- 
vening unaffected portions of the skin ; the 
color is darker than in scarlatina, with 
" nearly the hue of a raspberry," and inter- 
spersed with numerous small red papula?, 
disposed in clusters. 

5. Odor sweetish, until the decline of the 
eruption, then sourish. 

6. Principal sequelae: the same as scar- 
latina, with the exception of anasarca, in- 
flammation of joints, and gangrene. 



7. Exfoliation of the epidermis in furfura- 
ceous scales. 

8. More infectious and contagious than 
scarlatina. 

9. Frequently attacks the same person 
twice. 



The differences above stated amount at most to one of degree, the 
infection being the same in both disorders. Thus, while both are 
constituted by inflammation attacking the same textures of the body, 
scarlatina, during its first stages, is more rapidly and actively deter- 
mined to the cutaneous surface ; the mucous membrane, in an equal 
ratio, escaping the violence of the inflammatory action. The con- 
trary is the case with regard to rubeola ; here the cutaneous deter- 
mination is tardy and partial, while the mucous affection is gradual, 
severe, and prolonged. During the second stages, on the subsidence of 
the cutaneous congestion, the mucous membrane may suffer more or 
less in both, according to a variety of circumstances, such as the greater 
or less exhaustion of the morbific influence in the skin, the state of 
the nervous system, &c. These stages have no natural course in either 
disorder ; new and accidental or previously existing conditions deter- 
mining the resolution of the inflammation, or its attack upon some 
weak point of the mucous membrane. 

Scarlatina sine exanthemate is distinguished from cynanche maligna 
by the symptoms which indicate the presence of an acute disease, and 
one producing a powerful impression on the vascular and nervous 
systems. The alimentary system is also much disturbed; there is 
vomiting and diarrhoea, and the disease is apt to run its course to a 
fatal termination in the lapse of a few days, or within the first week. 
Angina maligna, on the other hand, is slow and gradual in its pro- 
gress, extending by degrees, from the point first attacked along the 
trachea and bronchial tubes, giving rise to the formation of false 

29 



450 DISEASES FROM UNKNOWN ANIMAL POISONS. 

membranes in its course, and attended with little constitutional disM 
turbance, however severe may be the local affection. In a word, tlJ 
observation of these two diseases exhibits, in the former, fatality fl 
its cause; in the latter, fatality in its effects. 

Causes. — The cause of scarlatina is an infection, or contagion, ap- 
parently identical with that of rubeola. It makes its attack in the 
form of an epidemic, and prevails mostly in the spring and autumn 
seasons of the year. The atmospheric conditions favorable to scarla- 
tina are cold and moisture combined, and the existence of this state 
of the weather ' for any time gives rise to a medical constitution, in 
which scarlatina is apt to be developed. When epidemics of scarla- 
tina and measles occur at successive periods, with an interval of a 
certain number of years, it would appear that the fresh invasion is 
determined by an increase in the numbers of the population who have 
not yet suffered from the disease, and who are consequently suscept- 
ible of its influence. Scarlatina is less contagious than rubeola, and 
affects children and young persons chiefly ; but many instances occur 
in which adults, and especially puerperal patients, have suffered from 
this disease. Scarlatina rarely attacks the same person more than 
once, and is less easily communicable by inoculation than measles. 
For protection against the propagation of the contagion, patients 
recovering from scarlatina should be secluded for a month or six 
weeks. 

It is worthy of remark, that an angina pseudo-membranosa, or 
diphtheria, complicated in some cases with scarlatina, not unfrequently 
takes place, on the Continent, in an epidemic form. In an epidemic 
of this disease lately reported to the Academy of Medicine, as having 
occurred at Lion-d' Angers, it prevailed for the first six months of the 
year. During the same period horses suffered from a similar affection, 
colts from acute enteritis, and cattle, sheep, and pigs, from phlyctenoid 
fever. 

Prognosis. — The prognosis of scarlatina will be much influenced 
by the nature of the prevailing epidemic. It sometimes invades with 
such overwhelming rapidity as to destroy life before any pathological 
changes can be effected. Scarlatina simplex is wholly divested of 
danger when it passes regularly through its course. It may, how- 
ever, be rendered grave by retrocession, or by complication with dis- 
ease in any of the viscera. " The prognosis is unfavorable if the 
delirium commence, as it frequently does in children, and sometimes 
also in adults, a few hours after the seizure. In these cases the child 
often dies on the third or fourth day, and the adult on the eighth or 
tenth. The tongue becoming brown; or, a clean tongue, with a 
rapid, fluttering pulse, are unfavorable symptoms. A sudden fading 
of the eruption, or its changing to a livid color, are symptoms of 
danger. The danger of scarlatina is increased by dentition. Preg- 
nancy also adds to the danger, as the woman frequently miscarries. 
The prognosis is also extremely grave when it attacks women imme- 
diately after parturition." "The fauces becoming livid under any 
circumstances, or an acrid discharge from the nostrils, or else the 
formation of an extensive abscess in the neck, accompanied with 



ERUPTIVE FEVERS. 451 

severe purging, are all unfavorable symptoms. The appearance of 
mortification in any part is commonly, but not universally fatal. 
Affection of the joints is a grave, but by no means a fatal symptom." 1 
The appearance of hemorrhage from the mucous membrane of the 
nose at the commencement of the exanthema is regarded as a favor- 
able sign. 

Treatment. — The principle of treatment- in scarlatina is to en- 
deavor to purify the blood of the morbid poison which it contains, 
and which is the cause of the disease, by calling into activity the 
various natural emunctories of the system, namely, the skin, the 
bowels, and the kidneys. The degree in which these powers should 
be set in action must be determined by the strength of the disease. In 
the mildest forms of the complaint the treatment should be of the 
simplest kind. Sydenham remarks, that none die of this disorder, 
except from a too great officiousness on the part of the practitioner, 
" niniia medici diligentia." The patient should be confined to the 
house, the sick apartment should be kept well ventilated, the patient's 
head cool, his feet warm, the bedclothes light ; his diet should be 
sparing and unstimulating, with an abundant supply of diluent and 
acidulated drinks ; conversation should be prohibited, and all sources 
of noise or moral excitement removed. To these hygienic means 
should be added, sponging of the skin with tepid vinegar ; a daily 
warm bath, if the process, can be accomplished without fatigue to the 
patient and danger of exposure; effervescent salines; mild diapho- 
retics, if necessary ; gentle laxatives ; and, at the decline of the fever, 
a mild tonic, such as the citrate of iron, or citrate of iron and quinine, 
and a little wine. During convalescence and after recovery, flannel 
should be worn next the skin. 

But scarlatina is not always so slight a disorder as to be amenable 
to the simple antiphlogistic method of treatment above laid down ; 
the want of a power of neutralizing the poison present in the blood, 
of a specific power, in fact, has long been felt by those who have the 
charge of treating this disease ; and in the absence of such a power 
the practitioner is compelled to deal with the disorder cautiously and 
even doubtingly, for at any moment the fever may put on a serious 
and dangerous aspect, and that which was benignant at first, may, in 
a few days, assume a fatal character ; or the type of the fever may be 
dangerous from the outset, for different epidemics of scarlatina differ 
in their qualities of danger, and in certain localities the fever is habit- 
ually more formidable than in others. Under the.se circumstances the 

| importance of a specific remedy cannot be too highly estimated ; a 
remedy which would control and neutralize the poison; that might be 

. administered safely at any stage of the fever ; that at the earliest 
dawn of the complaint would be prophylactic, and a certain cure in 
more advanced stages; that would prevent secondary affections, or 
conduct them safely through their course; in a Word, that would 
render scarlatina one of tin; slightest of human afflictions, instead of, 
being, as at present, one of the gravest of maladies. 

1 Dr. Robert Williams. Opus cit., p. 145. 



452 DISEASES FROM UNKNOWN ANIMAL POISONS. 



Such a remedy, a specific for scarlatina, my own experience tell 
me does exist, and has been employed and advocated for a number of 
years past by able practical men. A remedy that, in its power over 
scarlatina and rubeola, and probably variola, may be ranked with 
quinine in ague; iron in erysipelas ; arsenic in eczema; sulphur in 
scabies ; and mercury in syphilis. This remedy is the sesquicarbon- 
ate of ammonia, and has for its promoters and advocates, Peart, 1 
Wilkinson, 2 and Dr. Charles Witt. 3 The average dose for an adult is 
five grains in simple solution in water, administered every one or two 
hours throughout the course of the complaint. For an infant or child 
the dose may be two grains; and in severe cases it may be carried as 
high as ten grains. " Dr. Peart gave six-grain doses in cases of un- 
usual severity. Mr. Wilkinson rarely gave less than three grains, 
increasing the dose, according to the age of his patients, to ten grains, 
and repeating it more or less frequently according to the urgency of 
the case." Dr. Witt, in a case mentioned in his pamphlet, adminis- 
tered seven grains, " every hour, for the space of twenty-four hours, 
and during every alternate hour for the next like space, not only with 
perfect safety, but with complete success." 4 "Perfect quietude is 
especially required under the operation of this medicine. The patient 
is thrown by it into a sleepy state, as nearly as possible resembling 
the repose of health, and as long as that inclination remains, which is 
much to be desired, it should not be interrupted. In aid of this, the 
room should be somewhat darkened." The remedy possesses the 
power of tranquillizing the nervous system, calming nervous irrita- 
bility, and conducing to sleep ; it favors the development of the 
cutaneous efflorescence ; it reduces heat, fever, and delirium ; and, 
after a few hours, subdues any urgent complications that may be 
present, whether of the brain, the lungs, or the bowels. The sick 
apartment must be sufficiently ventilated, with an avoidance of 
draughts of cold air that might chill the surface and repel the 
eruption. 

It is important in the administration of ammonia, that it should be 
given alone; that nothing should be permitted in the diet of the patient 
that could neutralize its effects, such as acid drinks and fruits. The 
drink should be simple water, or toast and water ; the bowels should 
be regulated by gentle means, and the diet suited to the progress of 
the patient ; gruel, milk, and, as the fever subsides, broths and light 
nourishing food. 

1 Practical Information on the Malignant Scarlet Fever and Sore Throat. 

2 Remarks on Cutaneous Diseases. 1822. 

8 An Effectual and Simple Remedy for Scarlet Fever and Measles, with an Appendix 
of cases. 3d edition. 1S62, 

4 The case here referred to was peculiarly interesting, as showing the occasional 
irregular manifestation of the poison of scarlatina. The patient, a young lady, was seised 
with symptoms of inflammation of the bowels; after recovering from this attack, which 
confined her to bed for three days, she was attacked witja violent dyspnoea ; on the dis- 
turbance of respiration subsiding, she became restless and sleepless, and evinced symptoms 
of great cerebral irritation ; it was feared that the case would terminate in mania, when, on 
a sudden, the efflorescence of scarlatina was discovered on her skin. In forty eight hours 
this young lady took 252 grains of the sesquicarbonate of ammonia. 



. 




ERUPTIVE FEVERS. 

Ammonia was introduced into medical practice for the treatment of 
scarlatina by Dr. Peart in the beginning of the present century ; it 
was soon after adopted, on account of its unmistakable merits, by Mr. 
Wilkinson, and is now pressed upon the attention of the medical pro- 
fession by a scholar of Mr. Wilkinson's, Dr. Charles Witt. Out of 
several hundred cases of scarlatina, one gentleman has lost not more 
than one per cent, during a period of six years. Another practitioner 
rarely lost a patient during a practice of twenty years; but his suc- 
cessor, who rejected the treatment by ammonia, lost 74 out of 106 
cases during a single epidemic. In a public school, where the quinine 
and acid treatment prevailed, the number of deaths was rather more 
than ten per cent. Mr. Henry Jackson, senior surgeon to the Shef- 
field Infirmary, had, with his father, followed Dr. Peart's plan of treat- 
ment for upwards of fifty years, and during that period lost only four 
patients, who died in reality from typhus supervening on scarlatina. 
Mr. Wilkinson had not lost a patient from scarlatina or rubeola in 
twenty years. Dr. Peart himself records that after commencing the 
treatment by ammonia he did not lose one out of three hundred 
patients. His formula was a solution of two drachms of the sesqui- 
carbonate in five ounces of water ; and the dose, two drachms every 
two, three, or four hours, according to the urgency of the symptoms. 
When the difficulty of swallowing diminished, he permitted the addi- 
tion of water to the close of solution, if agreeable to the patient ; and 
he gave it in every form and stage of the disorder. " Some were 
glowing with universal efflorescence ; in some, the extremities were 
swelled ; in others, fetid ulcers appeared ; in most, the throat was 
swelled and inflamed, often ulcerated, and respiration almost pre- 
vented ; but, in the most alarming cases, a scorching fever and raging 
delirium rendered the patient's situation horribly distressing ; yet, in 
all these variations of the disease, the volatile alkali was my specific, 
which I administered to between two and three hundred patients, 
successively and successfully." 1 . ^-— _— - s - 

li' tlie extension of the disease to the kidneys should be indicated 
by anasarca, or the state of the urine, the warm bath must be imme- 
diately resorted to. It may be given twice a day, once a day, or every 
other day, according to the strength of the patient, and the relief it is 
found to afford; and its action may be increased by antimonial dia- 
phoretics. An active purgative, and such as will relieve the mucous 
membrane by exciting secretion, at the same time that it moves the 
bowels copiously, must be administered. Calomel, with the compound 
jalap powder, saline aperients, or drachm doses of the bitartrate of 
potash, are the best means for this purpose. And, in addition, the 
action of the kidneys may be gently aided by mild diuretics, such as 
the citrate of potash, acetate of potash, or liquor ammonise acetatis. 
But diuretics should be used with caution; judiciously selected and 
administered, I am of opinion that they would relieve the most con- 

1 Dr. Charles Win reminds us that " ii 1ms been long and generally acknowledged in 
those districts Oi England where the viper abounds, that when Buch poison has been 
infused into the system ammonia is the antidote." 



454 DISEASES FROM UNKNOWN ANIMAL POISONS. 

gested condition of the kidney; but, improperly chosen and mistimed 
in their exhibition, there would be danger of their increasing the 
inflammation which they are intended to abate. When symptoms 
indicate a very considerable congestion of the kidneys, leeches to the 
loins, sinapisms, or dry cupping, may become necessary. The com- 
pound tincture of iodine, containing an additional drachm of iodine 
to the ounce, I have seen used as a counter-stimulant with great 
success and relief. It possesses the advantage of ready application, ' 
arid may be used without the slightest disturbance of the patient. 
When symptoms denote effusion into the cranium or cavities of the 
brain, sinapisms or a blister should be applied to the nape of the 
neck. 

During the progress of the above treatment for carrying off the 
morbid poison, the powers of the digestive organs must be maintained 
by a nourishing diet ; and, as the symptoms subside, wine may be 
allowed for the same purpose. When the disease is exhausted, the 
general tone of the system, and especially that of the kidneys, is to be 
restored by means of mild chalybeate tonics, such as the citrate of 
iron, potassio-tartrate of iron, citrate of iron and quinine, vinum ferri, 
tincture of the sesquichloride, sesquioxide, or iodide of iron ; or, as 
recommended by Dr. Robert Williams, salicine, from combining the 
properties of a tonic and diuretic, in five-grain doses, three times 
a day. 

When the cause of the oedema or anasarca is an anaemic state of the 
system, tonic remedies are the appropriate treatment from the earliest 
indication of the existence of such a state ; the tonics best suited to the 
purpose being the salts of iron, alone or in combination with a bitter 
infusion ; or the sesquioxide of iron. 

In scarlatina anginosa, the same general plan of management should 
be adopted as in the preceding form ; and, if the heat of the skin be 
excessive, great relief will be afforded by sponging with cold or tepid 
water, vinegar and water, or tepid vinegar. The disposition to nausea 
which exists in scarlatina anginosa should be met by effervescing 
salines, such as the citrate of potash or ammonia, with hydrocyanic 
acid, combining with these remedies laxative doses of neutral salts. 
But, as the leading feature of scarlatina anginosa is inflammation of 
the mucous membrane of the fauces, this must be treated by the early 
application of nitrate of silver in the solid state. Some medical men 
give a preference to a strong solution, such as twenty or thirty grains 
to the ounce, applied by means of a sponge, but the solid stick appears 
to me to be most easily managed. The application should be repeated 
once or twice in the day. 

When the tonsils are enlarged and painful, and interfere seriously 
with respiration, or are accompanied by severe pain in the head, 
leeches should be applied to the submaxillary region, the number 
being regulated by the age and strength of the patient. In mode- 
rately strong children ten or twelve may be employed, but the 
abstraction of blood must be conducted with caution. If there be 
delirium the head should be shaved and cold applied. Blisters to the 
throat are objectionable in these cases, for, by exciting inflammation 



ERUPTIVE FEVERS. 455 

of the cutaneous surface, they act as an additional source of irritation; 
the tincture of iodine is not open to the same objection, and is an ex- 
cellent remedy. So long as the inflammation of the fauces continues, 
the saline remedies must be pursued; but as soon as the sloughs are 
thrown off, and ulceration established, and the febrile symptoms are 
on the decline, tonic medicines, with mineral acids and wine, are indi- 
cated. Acid and astringent gargles or fumigations, or, in young chil- 
dren, aspersion of the throat, with an acid and slightly astringent so- 
lution, are often useful in procuring the removal of the viscid mucus 
and exuviae which are apt to collect in the fauces and excite nausea. 
They also serve to remove the fetor which accompanies the sloughing 
and ulceration. 

Emetics have been recommended very strongly, as a means of 
clearing the throat of its mucus, and, at the same time, of ridding the 
stomach of its peccant contents. The violence of the remedy some- 
times outweighs the inconvenience which it is proposed to remove, and, 
although supported by the authority of Withering, emetics have fallen 
into discredit. 

Purgatives, like emetics, have been much overrated in the treatment 
of scarlatina anginosa. Willan was an advocate for the employment 
of calomel in purgative doses, with a view to reduce the febrile 
excitement and heat of surface. Dr. Hamilton also drew a favorable 
deduction from their use ; but Dr. Robert Williams has shown that 
while the mortality in the cases treated by Dr. Hamilton was twelve in 
ninety-five, in those treated by moderate stimulants it was only three 
per cent. 

Dr. Currie, of Liverpool, the celebrated advocate for the employ- 
ment of cold water in fevers, pursued this practice in scarlatina with 
remarkable success, washing the surface whenever the skin was "hot 
and dry." Dr. Batcman, and several other eminent physicians, 
adopted the practice of cold affusion, and gave the strongest evidence 
in its favor. The method of using the remedy is, to pour one or two 
pailful s of cold water over the patient, to rub him quickly dry, and 
place him in bed, where in a short space of time he falls asleep, and 
generally breaks out into a moderate perspiration. If the feeling of 
cold should continue after the bath, a little warm wine and water is 
administered. The effect of cold affusion is, to diminish the frequency 
of the pulse, to reduce the thirst and heat of skin, and to tranquillize 
the nervous system. If needful, it may be repeated a second or a 
third time. When affusion is not thought advisable, sponging the 
surface with cold water may be employed as a substitute. "Cold 
allusion," says Bateman, "combines in itself all the medicinal proper- 
tics which an- indicated in this state of disease, and which we should 
scarcely, a priori, expect it to possess; for it is not only the most 
effectual febrifuge, but it is, in fact, the only sudorific and anodyne 
which will not disappoint the expectation of the practitioner under 
these circumstances." "Invariably, in the course of a few minutes, 
the pulse lias been diminished in frequency, the thirst has abated, 
the tongue has become moist, a general free perspiration has broken 
forth, the skin has become soft and cool, and the eyes have brightened, 



456 DISEASES FROM UNKNOWN ANIMAL POISONS. 

and these indications of relief have been speedily followed by a calm 
and refreshing sleep." 

Dr. Schneemann, of Hanover, speaks in high terms of eulogium of 
a very simple treatment, namely, inunction with lard. 1 He says : 
From the first day of the illness, and as soon as we are certain of its 
nature, the patient must be rubbed every morning and evening over 
the whole body with a piece of bacon, in such a manner that a covering 
is everywhere applied. In order to make this rubbing-in somewhat 
easier, it is best to take a piece of bacon the size of the hand, choosing 
a part still armed with the rind, that we may have a firmer grasp. 
On the soft side of this piece slits are to be made in various directions, 
in order to allow the oozing of the fat ; and this is still further pro- 
moted by placing the bacon, for some time previously to using it, near 
the stove, in the oven, or on the hob, but the fat must be allowed to 
cool before its application. 

The rubbing must be most conscientiously performed, and not too 
quickly, in order that the skin may be thoroughly saturated ; and dur- 
ing the process only that part of the skin subjected to the operation 
should be exposed. This treatment should be continued night and 
morning for three weeks, and once a day for the fourth. After that, 
the patient may be washed daily with cool water and soap, and not 
until the skin has become accustomed to the cool ablution should the 
warm bath be commenced. 

The advantages of this plan Dr. Schneemann states to be the 
shortening of the disease to such an extent, that the patient may leave 
the house at the end of ten days ; the checking of all infection by the 
end of the third or fourth day ; the relief of all uneasy and painful 
feelings in the skin, particularly those that accompany desquamation ; 
the diminution of the amount of desquamation ; the prevention of 
taking cold ; and a greater security against complications and sequelae. 
The treatment, he observes, is not likely to find much favor with the 
fastidious, on account of being dirty, but the first few days of its ap- 
plication produce results which make all this to be forgotten, and in- 
spire mothers with enthusiasm. With a rapidity bordering on magic, 
all, even the most painful, symptoms of the disease are allayed ; quiet, 
sleep, appetite, and good humor return, and there remains only impa- 
tience to quit the sick-room. 

Dr. Mauthner, 2 of Vienna, adds his testimony in favor of the 
remedy ; and from my knowledge of the value of inunction in 
erysipelas, I am disposed to think most favorably of it. The principle 
of its action I believe to be the prevention of the too rapid oxygeni- 
zation of the blood at the surface of the body, and the consequent 
check to inflammation and its processes in the skin, one of the most 
important of those processes in diseases depending upon an animal 
poison being an augmentation of that poison. My friend, Mr. Grant- 
ham, of Crayford, in Kent, has for many years past relied on 

1 On Scarlet Fever, by Dr. Schneemann, translated by John L. Milton, M.R.C S.E., Lan- 
cet, September 15, 1849. 

2 Revue Medico-Chirurgicale, 1849. 



ERUPTIVE FEVERS. .457 

inunction in the treatment of violent sprains, and, at his recommen- 
dation, I have pursued the plan with extraordinary success ; the 
principle is the same, and falls into the same category as mercurial 
inunction in small-pox. 

Belladonna has obtained a high reputation among Continental 
practitioners for its protective and curative powers in scarlatina. It 
was first suggested in 1807 by Hahnemann, who had observed that all 
persons to whom this medicine had been given were preserved 
against the infection of scarlet fever. Several German physicians, 
who have recorded their experience in Huf eland 1 s Journal, unite in 
praise of belladonna ; one gentleman remarks that during an epidemic 
of scarlatina, fourteen children out of 195 exposed to the contagion, 
alone took^the disease, and those were but slightly affected ; another 
expresses his opinion, that belladonna may be considered as being as 
successful against scarlatina as vaccinia against small-pox. Several 
repeat the observation of Hahnemann, that the medicine produces an 
efflorescence on the skin similar to that of measles ; children in whom 
this efflorescence appears are at once regarded as safe. The reporters 
exhibit some disagreement in reference to the strength of the remedy : 
one recommends a solution of three grains of the extract to an ounce 
of cinnamon-water ; and of this solution he gives two or three drops 
to infants under a year, three or four drops during the second year, 
increasing the dose progressively until twelve years, at and after 
which period he administers twelve drops : another makes a solution 
of one grain to a drachm of water, and states the dose at ten to 
twenty drops, meaning, I apprehend, for an adult. Both these gentle- 
men prescribe the remedy twice a day ; while a third thinks it 
desirable to administer it four or five times a day, of course in 
corresponding doses. Dr. Schneemann, the originator of the inunc- 
tion treatment, proposes a solution of two grains of the extract in an 
ounce of cinnamon-water, and recommends, as the proper dose, as 
many drops, morning and night, as the child has years. The remedy 
should be continued, he observes, for at least fourteen days. 

Belladonna may also be given with advantage after the attack and 
during the progress of the fever, in doses of half a grain to two or 
three grains, according to the age of the patient, every three or four 
hours. 

Both cold affusion and belladonna appear to me to act therapeutically, 
by virtue of their sedative effects upon the nervous system ; and upon 
the same principle, any sedative means, from which the stimulant 
property were as much as possible excluded, would insure the same 
desirable end. Cold affusion has been used with great advantage in 
fevers, and the sedative powers of opium have lately been employed 
in France for the purpose of checking the inflammatory action. 

Dr. Sims remarks, in relation to prophylactic treatment : " The best 
preventive to the disease I found to be rhubarb, taken in the quantity 
of a few grains every morning, so as to produce one laxative motion 
in the day. I did not see one who used this confined afterwards to 
bed, though several persons began it after they were infected, but 
before the time of their sickening." 



458 DISEASES FROM UNKNOWN ANIMAL POISONS. 

Scarlatina maligna. — The vast depression of the powers of the 
nervous system that exists in scarlatina maligna indicates a tonic plan 
of treatment, conjoined with a proper regulation of the digestive 
system by means of gentle laxatives ; and attention to the local 
disorder of the throat. The best tonic remedies are quinine with 
infusion of roses and dilute sulphuric acid, gentian with nitric and 
hydrochloric acids, cascarilla, hops, or canella. The tonic and 
nutritive properties of wine or good beer render them invaluable 
remedies in these cases ; the quantity which may be taken daily by a 
child is from one to three ounces, and by an adult, double that 
quantity. The application of leeches to the throat is contra-indicated 
in the malignant form of scarlatina, and, indeed, no symptoms present 
themselves to warrant their use. The same objections oppose the 
application of blisters and counter-irritants. The fauces should 
be fumigated with the steam of warm vinegar, with decoctions of 
contrayerva and bark, acidulated with acetic acid, or containing 
camphorated spirit ; or gargled Avith a weak solution of chloride of 
lime or capsicum pods. Dr. Watson remarks, that a great improve- 
ment upon the old plan of capsicum gargles, is a weak solution of 
common salt either used as a gargle, or, if the disease occur "in a 
child that is not able to gargle, this solution may be injected into the 
nostrils and against the fauces by means of a syringe or elastic bottle. 
The effect of this application is sometimes most encouraging. ' A 
quantity of offensive sloughy matter is brought away ; the acrid dis- 
charge is rendered harmless ; the running from the nose and diarrhoea 
cease ; and the disease is converted into a form which approximates 
to the scarlatina anginosa." The surface of the body may be sponged 
with warm vinegar, but the use of cold water, so agreeable and 
beneficial in scarlatina anginosa, is painful and injurious in the 
malignant form. 

" Of late," observes Dr. Watson, " I have been in the habit of direct- 
ing a solution of the chlorate of potash in water (a drachm to a pint) 
as a drink for patients in scarlet fever, and in the typhoid forms of 
continued fever. This practice was suggested to me by Dr. Hunt, who 
tells me he has long employed it with advantage. Under the use of a 
pint or a pint and a half of this solution daily, I have remarked in 
many instances a speedy improvement of the tongue, which, from 
being furred, or brown and dry, has become cleaner and moist." Dr. 
Watson also remarks that the solution of chlorine has_b_een strongly 
pressed on his attention as a praiseworthy remedy. (" Two^arachms 
of the chlorate of potash are to be dissolved in two ounces of hydro- 
chloric acid previously diluted with two ounces of distilled water. 
r.^The solution must be put immediately in a stoppered bottle and kept 
in a dark place. Two drachms of this solution mixed with a pint of 
distilled water, constitute the chlorine mixture, of which a table- 
spoonful or two, according to the age of the patient, may be given for 

a dose, frequently." _____ _ , _ ^ ^ 

' Scarlatina sine exanthemata will require the treatment adapted for 
scarlatina anginosa or scarlatina maligna, according as it may put on 
the characters of either- of the preceding forms. -With the view of 



ERUPTIVE FEVERS. 459 

encouraging the development of the eruption, the skin should be 
stimulated by the hot air bath, warm bath, or mustard bath, by fric- 
tions with irritating applications, and by blisters. 

The retrocession of the cutaneous efflorescence in scarlatina should 
be treated with mustard baths, the application of blisters, and the 
friction of stimulating liniments on the skin. An eruption, evincing 
a disposition to metastasis, may frequently be fixed by means of a 
blister. 

Complications of scarlatina. — The complications of scarlatina call 
for a treatment especially directed to the organs aifected. Thus, when, 
from the presence of delirium and comatose symptoms, without much 
inflammation of the fauces, we are led to infer congestion of the brain, 
leeches should be applied to the temples or to the mucous membrane 
of the nose, in imitation of the critical hemorrhage which frequently 
occurs at the close of the disorder, and blisters should be placed be- 
hind the ears, or upon the nape of the neck. But when the symptoms 
are associated with inflammation of the fauces, the most ready, and 
indeed the only method of relieving them is to apply the leeches to 
the sub-maxillary region. It must, however, be borne in mind, that 
the delirium of scarlatina is very frequently an indication merely of 
irritation of the nervous system, and not of congestion; in which case 
the treatment must consist of opiates instead of depletory remedies. 
When respiration is obstructed from congestion or oedema of the 
mucous membrane of the larynx or trachea, leeches should be applied 
over this region, and in very severe cases, it may be necessary to per- 
form tracheotomy. When the lungs or pleurae are affected, leeches to 
the chest, with blisters or sinapisms, are required. When the stomach 
appears to be the seat of congestion, leeches to the epigastrium, and a 
blister or sinapism, will facilitate its restoration. Diarrhoea is to be 
relieved by leeches or fomentations to the abdomen, succeeded by 
sinapisms or a blister ; and the same plan is requisite when the kid- 
neys are the organs especially disordered, the therapeutic manage- 
ment in the whole of these cases being aided by mustard foot-baths. 
The cure of ulcerations in the fauces is best effected by means of a 
solution of nitrate of silver applied with a sponge; or by the same 
salt in powder blown upon the ulcerated surfaces through a quill. 

The inflammation of the joints that so frequently succeeds scarlatina, 
is combated by means of gentle purgatives, some simple sedative to 
relieve pain, and fomentations to the diseased articulations. . Other 
sci|iicl£e should be treated according to the general principles of thera- 
peutics. 

VARIOLA. 

Syn. Small-pox. Variole; Petite verole, Fran. Kinderpocken, 
Kinderblattern, Germ. 

Variola is an acute inflammation of the tegumentary investment of 
the entire body, both cutaneous and mucous, associated with fever of 
an infections and contagious kind. On the skin it is characterized by 
an eruption of red points, which pass through certain stages of pro- 



460 DISEASES FROM UNKNOWN ANIMAL POISONS. 

gressive development, becoming, in quick succession, pimples (vari), 
acuminated vesicles, flattened and umbilicated vesicles, pustules, and 
hard brown scabs ; the latter falling off from the eleventh to the 
twenty-fifth day, and leaving behind them small, irregular pits, and 
permanent cicatrices. On the mucous membranes it produces great 
congestion of surface, and in some situations pustules, particularly in 
the respiratory passages. The fever of variola is of the remittent 
type, preceding the eruption for two, three, or four days, ceasing as 
soon as the eruption is developed, and returning when the eruption 
has reached its height, namely, on the eighth day in discrete, and on 
the eleventh day in confluent, small-pox. 

Small-pox admits of several divisions in relation to the origin, dis- 
tribution, and degree of severity of the disease. In respect of origin 
it may occur sporadically, or be the consequence of the voluntary in- 
troduction of the variolous virus into the system, constituting the two 
varieties termed natural small-pox and inoculated small-pox. In reference 
to distribution and degree the eruption of small-pox may be discrete, 
the pustules being distinct, and scattered over the surface of the body ; 
it may be coherent, the pustules being very numerous, and, in many 
situations, placed closely side by side, but still distinct; it may be con- 
fluent, the pustules being very numerous, and, in several situations so 
closely set as to run one into the other, and form confluent clusters of 
various size; or it may be modified, the pustules being altered in their 
number, their size, and their course, either by the previous invasion 
of small-pox, natural or inoculated, or by vaccination. Modified small- 
pox is a much milder affection than the parent variola, and is termed 
varicella or varioloid. Another division of variola relates to its oc- 
currence for the first time, or as a second attack, a distinction which 
is expressed by the terms primary small-pox and secondary small-pox. 
Besides the preceding, we sometimes have occasion to remark, during 
the prevalence of an epidemic of variola, the occurrence of the fever of 
small-pox without its eruption ; this variolous fever constitutes a variety 
which has been appropriately termed variola sine variolis. These terms, 
expressive of differences in the character of variola, are chiefly useful 
for the purposes of communication and description. They may be 
comprehended at a glance, by placing them in a tabular form, thus : 

Natural variola — Discrete, 

Coherent, 

Confluent, 

Modified, 

Secondary. 
Inoculated variola. 
Variola sine variolis. 

The course of variola admits of consideration in five successive 
periods, this division being alike convenient in the treatment and de- 
scription of the disease. The periods of variola are those of incubation, 
invasion, eruption, suppuration, and desiccation. 

I. The period of incubation is of variable duration, and comprehends 
all that space of time which intervenes between the exposure of the 



ERUPTIVE FEVERS. 461 

body to infection or contagion, and the invasion of the disease. In 
very severe cases the period of incubation is short ; in the milder 
forms, on the contrary, it is long. The limits commonly assigned to 
this period are from five or six to twenty days, and cases sometimes 
occur in which it would seem to be still further prolonged. 

II. The period of invasion is marked by symptoms which indicate 
serious constitutional disturbance. It commences with languor and 
lassitude, with shivering and horripilation, pains in the head, in the 
loins, 1 and in the limbs : the skin is hot, and either dry or moist ; the 
conjunctivae suffused ; the pulse and respiration quickened ; there is 
thirst and loss of appetite, with a white and coated tongue, dotted with 
red papillae ; nausea, often vomiting, constipation, pain and heat at the 
epigastrium, restlessness, and universal prostration. To these succeed, 
though various in degree in different individuals, oppression of breath- 
ing, cough, lethargy, and sometimes coma. The tongue, at the com- 
mencement of this period, usually white, soon becomes red at the 
point, and subsequently over its entire surface. In children, convul- 
sions not unfrequently ensue at this stage of the febrile symptoms. 
Throughout all the periods there is exacerbation of the febrile symp- 
toms during the night. 

In confluent small-pox the symptoms of invasion attain their 
highest degree of severity, there is more sickness and vomiting, the 
prostration of the system is greater than in the discrete variety ; the 
tongue and lips are parched, and covered with sordes ; the heat of 
skin is excessive ; convulsions are more frequent, and sometimes there 
is diarrhoea. 

The period of invasion lasts from two to four days, and its symp- 
toms are instantly relieved by the succession of the eruptive period. 

III. The period of eruption is often ushered in by a manifest exacer- 
bation of the constitutional symptoms, which are at once and imme- 
diately relieved by the outburst of the eruption ; the oppression and 
languor are no longer felt, the nausea and sickness cease, the pulse 
returns to the natural standard, and is full and regular. The eruption 
first appears upon the lips and forehead, and then upon the rest of 
the face ; from the face it proceeds to the neck and arms ; from the 
latter to the trunk, and from the trunk to the lower extremities, the 
entire body being pervaded in the brief space of twenty-four hours.. 

The development of the eruption is indicated by the appearance of 
small red points, 2 conical in their form, and hard to the touch, which 
are disseminated over the surface in numbers proportionate to the 
subsequent pustules. Thus, in the discrete variety, the spots are few 
and distinct ; in the coherent kind, they are numerous and clustered 
(corymbose), like the patches of rubeola ; while, in confluent variola, 

1 M. Chomel regards the pain in the loins, which he refers to the kidneys, as patho- 
gnomonic. Dr. Heherden observed, that acute pain in the loins was generally followed by 
a severe attack of the disease; when the pain was higher in the back, the disorder was 
milder; and the most desirable indication was the absence of pain. Mr. Marson, of the 
London Small-pox Hospital, considers the pain in the loins to result from the passage of the 
variolous poison through the vessels of the kidney, thus exciting a painful state of the 
nerves of that organ. 

2 By some writers these points have been compared to the spots produced by the bite 
of the flea. 



462 DISEASES FROM UNKNOWN ANIMAL POISONS. 

they are closely aggregated, and so abundant as to diffuse a general 
redness over the surface. The skin is hot, tense, and shining. The 
red spots soon become raised, and by the second day of eruption (fourth 
or fifth of invasion) have the appearance of small conical papulse 
(vari), with red and inflamed bases, and transparent and vesicular 
points. On the third, fourth, and fifth day of eruption (fifth to ninth 
of invasion), the papular elevations, with their inflamed bases, go on 
progressively enlarging, the vesicles pass from a conical into a 
depressed and indented or umbilicated form ; their contents, which 
were at first a transparent lymph, become whitish and milky, and a 
thin layer of white coagulum is formed on the derma. The umbilicated 
character is apparent in many of the vesicles on the third day of 
the eruption, and by the fourth or fifth, a distinct areola is apparent 
around each. 

Similar phenomena may be observed to be taking place at the 
same time in the mouth and pharynx ; the mucous membrane is red, 
swollen, and congested ; there is soreness of the throat, and painful 
deglutition ; the respiration is somewhat impeded in consequence of 
the extension of the inflammation to the larynx and trachea ; the 
voice is hoarse and weak ; and there is frequently a hard, dry, and 
troublesome cough. The eruption is developed in the larynx and 
trachea, on the pharynx and fauces, and on the tongue, in the form 
of white points, which become converted, first into vesicles, then into 
pustules. 

In the confluent variety the remission of febrile symptoms is imper- 
fect, the eruption appears a day earlier than in the discrete form, the 
papulae are less raised, but so numerous as to give rise to a general 
swelling of the skin, which is of a deep red color, shining and granu- 
lated. The incipient pustules constitute one continuous vesicle over 
the inflamed surface, formed by the effusion of liquor sanguinis or 
coagulable lymph beneath the epidermis. This fluid, at first trans- 
parent and limpid, becomes milky and opaque, and a thin whitish 
pellicle of false membrane is deposited on the derma, and may be seen 
through the raised epidermis. 

The confluent and the discrete variety of small-pox frequently 
occur together in the same individual, the eruption being confluent 
on the face, 1 and discrete on the rest of the body. When the con- 
fluent form extends to the mouth and pharynx, the mucous membrane 
is covered with pustules, deglutition is rendered exceedingly painful, 
and respiration is seriously impeded. In the trachea the eruption 
gives rise to cough, and in the nasal passages to sneezing and catarrh. 
On the eyelids the pustules produce great tumefaction and severe 
in il animation of the conjunctiva. 

The eruptive period occupies five days : one corresponding with 
the varous stage, and the four following with the vesicular stage. 

1 The eruption is always most confluent on those parts of the body where some external 
source of irritation is added to that of the disease. Hence the eruption is most abundant 
on the face, hands, buttocks, and inner sides of the thighs of children. Sydenham re- 
marks, that if there be 10,000 pustules on the entire body, 2000 of these will occupy the 



ERUPTIVE FEVERS. 463 

IV. The period of suppuration or maturation commences on the sixth 
day of eruption (ninth or tenth of invasion), by augmentation of the 
contents of the vesicles, and conversion of their contained lymph 
into pus. As a consequence of this change, the vesicles lose their 
umbilicated character ; they become spheroidal and flattened, and 
their whitish appearance gives place to a tint of yellow of increasing 
depth. Maturation is complete on the eighth day of eruption. On 
the eighth day, also, the secondary fever is developed, and continues 
until the eleventh, during which time the pustules burst, and give 
exit to a portion of their contents : the period of desiccation is then 
established. 

In the confluent variety, the inflammation, instead of being confined 
to a number of distinct points, is distributed over a large surface ; 
isolated pustules, consequently, are not formed, but the production of 
pus occupies a district of considerable extent. On the face, the raised 
epidermis frequently begins to desiccate into a thin yellowish crust 
before the formation of pus is completed ; the pus in this case is 
effused beneath the crust, giving to it additional thickness, and a 
characteristic brownish hue. 

Suppuration is first perceived on the face, whence it extends to the 
rest of the body, showing a disposition to affect those parts first which 
possess the thinnest and most delicate skin. For this reason it is that 
the feet and hands are the parts last observed to undergo the suppurative 
change. The completion of the suppurative stage on the eighth day 
of eruption, is attended with considerable pain and throbbing, with a 
vivid redness of the skin, great tumefaction, and a distressing sensa- 
tion of tension of the integument. The swelling affects, in the first 
instance, the head and face, from these it extends to the trunk and 
limbs, and from the latter to the hands and feet. The eyelids are 
often so much swollen as completely to bury the eyes; the nose and 
lips are much enlarged ; there is swelling and congestion of the 
mucous membrane of the mouth, and (in the adult) profuse salivation; 
the lining membrane of the alimentary canal sympathizes in the 
general irritation of the mucous surfaces, as may be inferred from the 
presence of diarrhoea. And the nervous system is greatly depressed, 
as is shown by the listlessness and lethargy which are conspicuous at 
this period. 

With tli is extreme of local disorder, the secondary fever is estab- 
lished, and continues unabated until the close of the eleventh day of 
eruption. In mild cases this stage is accompanied with moderate 
delirium. But in more severe cases the tongue becomes brown, the 
symptoms assume the low typhoid type, there is hard cough, with 
haemoptysis, and sometimes hematuria. 

In confluent small-pox the secondary fever is not developed until 
the eleventh day ; the symptoms are severe, and often accompanied 
by restlessness, which increases towards night. This state of restless- 
ness is a dangerous symptom. 

V. The period of desiccation is indicated by subsidence of tumefaction 
of the skin, by the drying up of the pus and purulent discharge 
produced during the preceding period, and by the conversion of these 



464 DISEASES FROM UNKNOWN ANIMAL POISONS. 

fluids into scabs of various thickness. Desiccation commences on the 
face much earlier (eighth day of eruption) than on the rest of the 
body, and it not unfrequently happens that crusts are present in this 
region before the pustules have attained maturity on the limbs. The 
crusts are formed in two ways, either by rupture of the pustules and 
desiccation of the purulent discharge which is poured out by the 
exposed and ulcerated surface, or by desiccation of the entire pustule 
with its investing epidermis. The former is the more frequent 
method of their production. When the crusts fall, an event that 
occurs upon successive parts of the body, from the eleventh to the 
fourteenth day of eruption, the skin beneath is of a bright red color, 
retaining this hue for several weeks, and the newly-formed epidermis 
is thrown off by repeated desquamation. The cicatrices also which 
have been produced by the ulcerations now become apparent. 

In the confluent variety, as has been already remarked, the crust 
on the face commences to be formed before the completion of the 
suppurative process, often as early as the eighth or ninth day of the 
eruption. This extensive crust forms a complete mask to the features, 
and remains attached for ten or twelve days. When it falls off, the 
skin beneath presents a vivid red color, and desquamates freely, 
bringing into view a surface too frequently disfigured with deep pits, 
and seamed with extensive cicatrices. The crusts of confluent small- 
pox are softened with the fluids poured out by the inflamed skin, and 
their fall is not completed till the twentieth or twenty-fifth day. 

The desiccation of the pustules of small-pox is attended with severe 
itching, which induces the patient to scratch, and often to tear the 
surface with his nails. By this proceeding hemorrhage takes place 
from the ulcerated surface, and the drying of the blood gives rise to 
a black discoloration of the scabs which form over the wounded parts. 
The desiccation of the pus and of the purulent discharges is attended 
with a nauseous and offensive odor. 

It is remarked by Simon, that the urinary secretion in variola 
undergoes changes having relation to the various stages of the disease. 
That, in the beginning, when the fever assumes the character of 
synocha, the urine is diminished in quantity, and increased in specific 
gravity ; its color is deep and red ; it is frequently turbid, and often 
contains a small quantity of albumen. In the eruptive stage, as 
ascertained by Becquerel, in five cases, in which the symptoms were 
severe, " the urinary secretion was diminished, and amounted on an 
average to only 23.5 ounces in twenty-four hours. The specific 
gravity had not, however, increased so much as might have been 
supposed, being only 1020.6. It frequently threw down uric acid 
precipitates, either spontaneously, or on the addition of nitric acid, 
and in one case a little albumen was observed." "According to 
Schonlein, in the first stage of variola, it is of a reddish-brown tint ; 
on the third or fourth day a sweat of a peculiar and strong odor is 
observed, and the urine contains a turbid, apparently purulent mucous 
sediment, of an unpleasant odor." 

" During the suppurative stage of variola, Becquerel observed that 
the urine retained the synochal character as long as the symptoms 



ERUPTIVE FEVERS. 465 

continued." And in cases in which this fever persisted until death, 
the state of the urine also remained the same. Sediments and fre- 
quently purulent mucus occur in the urine of this period. 

" During the period of desquamation the urine is either normal or 
anaemic." 

In the nervous form of variola the urine is very changeable, and 
often dark. " In the putrid form the urine appears decomposed, am- 
moniacal, and not unfrequently of a dark red color, from the presence 
of hsematin." 1 

INOCULATED VARIOLA. 

The intent of the operation of inoculation is to bring some portion 
of the fluid contained within the small-pox vesicle into relation, either 
with the papillary surface of the derma, or with the tissues situated 
immediately beneath the epidermis of a sound person. When this 
object has been effected, the inoculated particles dissolved in the fluids 
of the tissues are conveyed by imbibition into the system, and commu- 
nicate to the whole mass of the blood a disposition to the production 
of matter of a similar kind. 

The local signs indicating that the inoculation has taken e'ffect are 
first perceived on the third day from the operation, when a slight 
blush of redness is seen around the puncture ; this is accompanied by 
a trifling degree of itching, and the skin feels hard and dense when 
touched with the finger. On the fourth and the fifth day these signs 
continue gradually to increase ; there is a sensation of prickling and 
tingling in the inoculated spot, and a small elevation begins to be 
formed in the centre of the areola. On the sixth day an incipient 
pustule is produced by the effusion of liquor sanguinis beneath the 
epidermis, the vesicle at this period begins to be depressed at its 
centre, and to assume the umbilicated appearance. On the seventh 
day tbere is tenderness of the integument around the vesicle, and 
some degreee of pain on moving the arm ; the vesicle begins to look 
whitish and opaque ; the contained lymph quickly gives way to the 
formation of pus, and the vesicle is surrounded by a purplish areola. 
By the ninth or the tenth day the pustule has lost its umbilicated 
character, and has attained its perfect development. After the com- 
pletion of the pustule the areola declines in redness, and its contents 
desiccate, the desiccation taking place during the period intervening 
between the twelfth and the fifteenth day, and forming a scab of a 
deep brown color, and considerable thickness. The crust is thrown 
off during the period ranging from the twentieth to the twenty-fifth 
day, and is succeeded by a strongly marked cicatrix, which remains 
apparent for the rest of life. 

The period of invasion of the constitutional symptoms in inoculated 
small-pox usually commences on the ninth day. They resemble in 
character those of sporadic variola, but are mild, and sometimes so 
slight as to be scarcely recognizable. Instances are occasionally met 
with in which the symptoms of invasion are developed, and followed 

1 Simon, vol. ii. p. 282. 
30 



466 DISEASES FROM UNKNOWN ANIMAL POISONS. 

by eruption, without any signs of inflammation in the inoculated part, 
and consequently without the formation of a pustule. 

The period of eruption in inoculated small-pox is irregular, the 
eruption appearing generally on the second or third day from inva- 
sion, or on the eleventh or twelfth from inoculation. Occasionally it 
is observed at the end of a week after inoculation, and sometimes is 
protracted to a fortnight. The eruption is ordinarily very slight, 
sometimes failing altogether, or being scarcely perceptible ; while, in 
rare instances, it may occur at several successive periods, or the con- 
fluent variety of eruption be developed. 

The eruptive period of inoculated small-pox is sometimes complicated 
with an erythematous inflammation of the skin, constituting variolous 
roseola. 

VARIOLA SINE VARIOLIS. 

This form of variola is rare ; it has, however, been occasionally 
observed during the prevalence of an epidemic of variola, and is 
characterized by the presence of the constitutional symptoms and 
mucous inflammation of that disease without the cutaneous eruption. 
Sydenham assigned to this affection the name of variolous fever, and 
the accuracy of his observations has been confirmed by subsequent 
writers. Rayer remarks that he has never seen an instance of this 
variety of small-pox. 

COMPLICATIONS OF VARIOLA. 

Hitherto the favorable course only of variola has been described, 
but the disease is not unfrequently attended with complications, which 
give it the character of a dangerous and often fatal disorder. These 
complications may occur during any one of the five periods into 
which the progress of the affection has been divided. 

Instead of pursuing the milder course above indicated, the period 
of invasion is occasionally marked by symptoms of excessive severity, 
the accompanying fever runs high, the rigor which precedes it has 
been long and enduring, and the pains in the head, the chest, the 
prrecordia, and the loins, are so violent as to lead to the suspicion of 
inflammation of organs situated in those regions. There is sometimes 
delirium and coma, at other times convulsions; and death may occur 
before the eruptive stage is established. In cachectic states of the sys- 
tem the period of invasion is sometimes complicated with passive 
hemorrhages from the mucous membranes and from any trifling wound 
of the skin, and by petechise in the tissues of both structures. 

The period of eruption, like the preceding, is liable to its accidents; 
instead of the favorable course already noted, serious congestions of 
one or more of the internal viscera may ensue. Sometimes the con- 
gestion is directed upon the brain and spinal cord, producing twitching 
of the muscles, restlessness, convulsions, or coma; sometimes on the 
lungs, causing bronchitis, pneumonia, or pleurisy ; sometimes on the 
mucous membrane of the alimentary canal, giving rise to diarrhoea, 
dysentery, or hemorrhage ; and sometimes upon other of the abdo- 



ERUPTIVE FEVERS. 467 

minal organs. In the cachectic diathesis, passive hemorrhages and 
petechise may accompany this period ; and under any of the above 
complications, the case may prove fatal before the completion of the 
eruption. The eruptive process is liable to suffer seriously by these 
complications ; thus, the variolous vesicles, instead of progressing, 
become stationary and flaccid, or distended with a sanguinolent and 
serous fluid. 

The period of suppuration, as it is the most severe in its symp- 
toms, is also the most dangerous in its complications, and the most 
frequently fatal in its results. Alarming symptoms sometimes appear 
with astonishing rapidity, and destroy life in a few hours, or even in 
a shorter period. Affections of the brain, of the larynx, and of the 
trachea, are most to be apprehended during this period. When these 
secondary affections are severe, the pustules remain stationary, or 
become flaccid, or are converted into sanguinolent bullae ; sometimes 
they are accompanied with petechiae and passive hemorrhages, and 
in rare cases disappear, by the absorption of their purulent contents. 
The latter occurrence is always fatal. Other dangerous indications of 
this period are, the absence of tumefaction and redness of the skin, 
the absence of salivation, the appearance of the brown tongue of typhus, 
restlessness and anxiety, mortification of any part of the skin, &c 

The termination of variola is a period of much anxiety ; for when 
the disorder has run favorably through its stages, and the danger of 
the disease has apparently passed away, secondary affections are not 
uncommonly developed, as consequences of the variolous inflamma- 
tion. Such are, chronic inflammation of the various mucous mem- 
branes, producing deafness, ophthalmia, opacity of the cornea, staphy- 
loma, oedema glottidis, haemoptysis, pulmonary tubercles, chronic 
bronchitis, pneumonia, pleuritis, empyema, chronic diarrhoea, &c, 
glandular enlargement, caries of the bones of the face, subcutaneous 
abscesses, furuncles, erysipelas, gangrene of the skin, disease of joints, 
monorrhagia, miscarriage, haematuria, abscess of the kidney, and 
numerous other sequelae. The cause of these various complications 
must be referred to some peculiarity of constitution, and cannot be 
explained by ordinary circumstances. Sometimes they would appear to 
depend on the vicissitudes of season, the depth of winter and the height 
of summer being most frequently attended by adverse consequences. 

Variola is occasionally complicated with rubeola and scarlatina, and 
sometimes with petechias. The latter form of small-pox is very severe 
in its affection of the mucous membranes and viscera, but the cerebral 
symptoms assume a milder type. 

Pathology. — On examination after death of those who have fallen 
victims lo small-pox, several of the internal organs are found to pre- 
sent traces of congestion, particularly the brain, the lungs, and the 
surface of the gastro-intestina] mucous membrane. The tissue of the 
lungs is generally found congested and infiltrated, and the serous coat 
of the bloodvessels stained of a deep red color. Pustules are dis- 
covered upon the mucous membrane only when the patient chances 
to perish at the commencement of the suppurative stage. At a later 



468 DISEASES FROM UNKNOWN ANIMAL POISONS. 

period they are usually lost, on account of the early rupture of the 
epithelium, which from its thinness and softness, is less resistant than 
the horny epidermis. For the same reason, pustules on the mucous 
memhranes never attain a size equal to those of the cutaneous surface, 
and rarely contain pus. When ruptured, the surfaces occupied by 
these pustules are found to be covered with loose laminae, and shreds 
of false membrane. 

The situations in which pustules have been observed on mucous 
surfaces are, the extremities of the alimentary canal, where the epi- 
thelium is thick, namely, in the mouth, pharynx, oesophagus, and rec- 
tum ; Rostan detected them throughout the entire intestinal canal, on 
the respiratory mucous membrane, namely, in the larynx, trachea, 
and bronchi, and in the urinary bladder. 

The form of the pustule of small-pox is strikingly modified in re- 
ference to the seat of its development. Thus, on the face, where the 
pustules advance very rapidly to maturity, they are flat and non-um- 
bilicated. On the palms of the hands, and on the palmar surface of 
the fingers, they rise gradually from the surface, are but little raised 
above the level of the surrounding skin, and are also non-umbilicated. 
On the soles of the feet, again, they are large in extent, and still more 
flat* than the preceding, appearing like purplish disks with a white 
margin, and non-umbilicated. Usually, the umbilicated centre pre- 
sents a reddish or brownish tint, and sometimes, though rarely, is per- 
forated by the shaft of a hair. 

When a well-formed and mature pustule is examined by dissection, 
it is found to be divided in its interior by a transverse septum into 
two chambers, both containing pus. The upper chamber is the larger 
of the two, and they communicate with each other, to a greater or less 
extent, by the rupture of the transverse septum around its marginal 
border. The epidermis, forming the superficial boundary of the pustule 
is the segment of a sphere, and continuous by its circumference with 
the cuticle covering the adjoining skin. The transverse septum is a 
layer of false membrane, of a whitish color, which w T as deposited on 
the derma at an early stage of the pustule. Subsequently this layer 
becomes separated from the derma, and raised by the formation of pus 
beneath it, and at the same time it is broken around its edges, and 
permits the pus of the deeper cavity to communicate with that already 
contained in the superficial chamber. In consequence of the pecu- 
liarity in the mode of its production, this layer of false membrane 
generally retains permanently the umbilicated form of the primitive 
pustule, and is thinner at the centre than towards its circumference. 
When the septum is removed, the deep chamber is brought into view, 
and the depressed and sometimes ulcerated base of the pock exposed. 
The surface of the base is of a bright or purplish-red color, and highly 
vascular. 

Some difference of opinion subsists with regard to the cause of the 
umbilicated appearance of the pustule of variola during its early stages. 
Dr. Heming many years since attributed it to the perforation of the 
pustule by the efferent duct of a sebiparous gland. Velpeau, who 
believes that the principal seat of small-pox is the follicles of the 



ERUPTIVE FEVERS. 469 

derma, would, I suppose, entertain the same opinion. Other writers 
believe it to be produced by the pores of the skin, and Rayer refers it 
to the attachment of the false membrane. I agree with Velpeau that 
the follicles of the skin are the primary seat of the vascular conges- 
tion, that this congestion gives rise to the production of the papules 
or vari, and consequently that the epidermal sheath of the follicle is 
the probable-cause of the umbilication of the small-pox vesicle. When 
the vesicle is examined at its height of development, it is found to be 
ni unilocular in structure, and, when divided by a transverse section, 
exhibits an appearance which Gendrin has compared to a spice-box, 
while Bousquet likens it to a severed orange. 

Diagnosis. — The precursory symptoms of small-pox are liable to 
be mistaken for simple fever, or inflammation of such of the viscera 
as may chance to be most affected. Pains in the loins, according to 
Chomel, are pathognomonic ; vomiting is more usual, and the pains 
in the limbs are somewhat greater than in other exanthemata, and 
convulsions in children are more frequent. The prevalence of an 
epidemic of this disease, or the previous exposure of the individual to 
the influence of contagion, are alone calculated to raise suspicion in 
the mind of the practitioner until the true nature of the symptoms is 
confessed by the appearance of the eruption. When first developed 
the eruption presents considerable resemblance to rubeola, but from 
the latter it may be distinguished, as well by the nature of the pre- 
vious symptoms as by the more decidedly papular character of the 
eruption, and the rough sensation which the papulae communicate to 
the finger. It is utterly impossible to confound the mature pustules 
of small-pox with any of the pustular affections of the skin. 

Causes. — It is affirmed by Mr. Moore, in his History of Small- 
pox, that this disease existed in China and Hindostan more than 
1000 years before the birth of Christ. After a long period it appears 
to have made its way into Arabia, and to have shown itself in the 
Arab host at the siege of Mecca, in the year of the birth of Maho- 
met, 509. Pursuing the track of armies we find it raging in Egypt in 
640, and subsequently following the victories of the Saracens in the 
eighth century, through Italy, Spain, and France. By the Saracens 
the disease was communicated to the Crusaders, and the latter caused 
its rapid spread throughout Europe. " There was no small-pox in the 
new world before its discovery by Columbus in 1492. In 1517, the 
disease was imported into St. Domingo. Three years later, in one of 
the Spanish expeditions from Cuba to Mexico, a negro, covered with 
the pustules of small-pox, was landed on the Mexican coast. From 
him the disease Bprea'd with such desolation, that within a very short 
timr, according to Robertson, three millions and a half of people were 
destroyed in that kingdom alone. Small-pox was introduced into Ice- 
laud in 1707, when 16,000 persons were carried off by its ravages, 
more than a fourth part of the whole population of the island. It 
reached Greenland still later; appearing there for the first time in 
1733, and spreading so fatally as almost to depopulate the country." ! 

1 Dr. Watson's Lectures, first edition, vol. ii. p. G57. 



470 DISEASES FROM UNKNOWN ANIMAL POISONS. 

Small-pox occurs at all periods of life, from the foetus in the womb 
to the last hours of senility. It is developed equally in the two sexes, 
in all seasons, and in all climates. It may appear as a sporadic affec- 
tion, or epidemically. In the latter form its invasion is most fre- 
quently observed in the summer or the autumn season. 

The cause of small-pox is a specific animal poison ;' the period 
when transmission is most likely to happen being the suppurative 
stage, and when developed epidemically, it is propagated in the direc- 
tion of prevailing winds. As a general rule, small-pox attacks but 
once in a lifetime, but against this rule many exceptions have been 
recorded. Instances have been observed, in which the disease has 
invaded a second, a third, and even so often as a sixth time. Some- 
times the subsequent attack is as severe as the first, but usually the 
secondary affections are remarkable for mildness and rapidity of course. 

The protective agency of an attack of variola against subsequent 
invasions of the disease was known at a very early period in medical 
history ; thus, inoculation was practised in Constantinople in 1673, 
and the practice was subsequently introduced by Lady Montague 
into England, whence it extended to the Continent of Europe. The 
intention of inoculation is to produce an attack of the disorder, at a 
period when the physical powers are sound and capable of resisting 
its influence ; moreover, it is found that the inoculated disease is 
always more mild than the sporadic affection. Several serious objec- 
tions, however, raise themselves against inoculation, and one of these 
so great as to have been deemed worthy of a restrictive Act of the 
Legislature. The most obvious reasons that oppose themselves are, 
firstly, that the system is equally, perhaps more safely, protected by 
the milder operation of vaccination ; and, secondly, that inoculation 
often produces a severe and dangerous disease. But the most im- 
portant objection to the continuance of the practice is, that the small- 
pox engendered by inoculation, may be communicated to others by 
contagion ; and, consequently, that one such case may become the 
source of a fatal and devastating epidemic. An instance of this kind 
is related in the memoirs of Maria-Theresa of Austria, who, having 
inoculated a number of children, the small-pox was communicated 
by the latter to an entire village. 

Prognosis. — In the discrete form of variola, or when the eruption 
is slight, and its course mild, the prognosis is favorable, the disease 
usually terminating in from two to three weeks. In the confluent 
form there is considerable danger, and the disorder requires to be 
watched with care, for symptoms of a fatal nature are apt to show 
themselves suddenly and unexpectedly, and the disease is prolonged 
to three or four weeks. Small-pox is of unfavorable prognosis when 
it presents irregularities in its course ; when it is complicated with 
much cerebro-spinal or pulmonary irritation ; when the pustules contain 
a sanguineous fluid, or are intermingled with petechise ; when the 

1 Several authors have imagined the cutaneous eruption of small-pox to depend u|>on 
the presence of minute animalcules; but careful observation aflbrds no ground for this 
supposition. 



ERUPTIVE FEVERS. 471 

eruption is associated with debility of system in the patient, or with 
signs of mental depression, as fear, &c. ; when the pock does not pass 
regularly through its stages, or when the persons affected are plethoric, 
and unused to disease. 

Treatment. — The uncomplicated form of small-pox requires the 
most simple plan of treatment, namely, confinement to bed, diluents, 
cooling regimen, cool and equable temperature, frequent change of 
linen, and an attention to symptoms as they arise. Meddling in 
variola is calculated to be as injurious as in other eruptive diseases 
depending for their origin on a specific poison ; and it must be borne 
in mind, that any vascular determination to the surface, whether 
internal or external, will be followed by an increase in the number 
of pustules developed on the irritated spot. Thus an incautious 
purgative at the outset of the fever may induce a congestion of the 
mucous membrane of the alimentary canal that may terminate 
seriously. 

The treatment of variola in its simple form is consequently expect- 
ant ; very little is required of the practitioner during the fever of 
invasion beyond the maintenance of a cooling regimen, keeping the 
b6wels gently open by saline purgatives, and sponging the skin with 
tepid water. 

At the commencement of the secondary fever, the proper remedies 
are febrifuge salines, such as the citrate of potash, or liquor ammonise 
acetatis, or effervescent salines ; and at a more advanced period, a 
continuance of gentle laxatives or enemata, and opiates to relieve 
restlessness, sleeplessness, and nervous symptoms. Should the powers 
of the system seem to require support, this is the period when wine 
and a more nourishing diet may be allowed ; the effects of the wine 
being carefully watched. 

The sesquicarbonate of ammonia treatment, so valuable in rubeola 
and scarlatina, is equally applicable to variola, for ammonia is, pro- 
bably, as Dr. Charles Witt observes, "the only medicine yet known 
which appears to have any decided effect upon this terrible malady;" 1 
that is as a specific remedy. The manner of administration of the 
ammonia should be the same as that laid dowrf under the head of 
treatment of scarlatina ; and the general precautions taken, and the 
management of the patient, should be the same. My own experience 
of the sesquicarbonate of ammonia fully corroborates the value of 
Dr. Witt's suggestion ; and I feel that the adoption of this method of 
treatment cannot be too forcibly pressed on the attention of medical 
men. If it be capable of effecting only one-half of what its advocates 
claim in its favor, it must, of a necessity, rank among the most valua- 
ble of our remedial appliances. 

1 Dr. Charles Witt mentions a paper read at the Epidemiological Society of London, 
f'roi m tin- pen of Mr. H. C. Miles, of the Royal Artillery, Halifax, on the subject of a remedy 
liii amall-pox, used by the Indian tribes, in that portion of Canada. This remedy is an in- 
fusion of the Saracenia purpurea, a variety of the pitcher plant. A wineglassful of the 
infusion throws 0U1 the eruption ; ami the same dose repeated once or twice, after an in- 
terval of four or six hours, puts an end to it completely. During the prevalence of an epi 
demic a wineglassful is taken daily as a prophylactic. 



472 DISEASES FROM UNKNOWN ANIMAL POISONS. 

If the cerebro-spinal system be much disturbed, leeches to the 
mucous membrane of the nose or behind the ears, with mustard foot- 
baths, are indicated ; gargles for inflammation and dryness of the 
mucous membrane of the mouth and fauces; leeches to the epigastrium 
for pains in that region with violent vomiting ; mineral acids with in- 
fusion of roses, for hemorrhages ; and emollient applications to the 
eyelids where the conjunctivae are painful and swollen. If the eruption 
be tardy in its appearance, the patient may be immersed in a warm 
bath, at the same time that tartarized antimony and sudorifics are ad- 
ministered internally. Opiates are contra-indicated in the primary 
fever, on account of the extreme excitability of the nervous system; 
in the secondary fever they are frequently useful. Sydenham recom- 
mended a small bleeding at the commencement of the secondary fever, 
and following it up with an opiate ; but he cautions us against abstract- 
ing too much blood. The safer practice is not to bleed, and in this 
opinion the profession are generally agreed. 

These are the remedies which are applicable to small-pox in its 
ordinary and uncomplicated form ; but when the disease assumes any 
of the unfavorable characters which have been described, other mea- 
sures are indicated, such as local bleedings, and counter-irritation. 
Local bleeding by leeches or cupping may be employed at any period 
of the disease, when the symptoms indicate serious congestion of vis- 
cera ; the abstraction of blood must, however, be conducted with cau- 
tion, lest too great debility follow its use. Counter-irritation is appli- 
cable when the removal of blood by bleeding would be inadmissible. 
Under the same circumstances, again, mild purgatives may be admin- 
istered, when symptoms of gastro-intestinal irritation are absent. But 
purgatives, it must be recollected, are calculated to excite and keep up 
irritation of the mucous membrane, and they may frequently be very 
judiciously superseded by emollient injections. At the close, of the 
eruption, the employment of gentle laxatives is indicated, and, if much 
debility be present, tonics should be had recourse to, and their action 
aided by wine and nutritious diet. When there is pain and heat of 
head, with delirium, which depletion from the mucous membrane of the 
nose and behind the ears has been unsuccessful in removing, ice may 
be applied to the head, or the cold water pillows recommended by the 
late Professor Davis for hydrocephalus, or, still better, the cold 
cushions of Dr. James Arnott. 1 

When the nervous system is especially affected, as in that variety 
termed by Dr. Gregory nervous variola, the administration of tonics is 
called for ; and similar means must be adopted when there is evidence 
of a cachectic state of constitution, as in the occurrence of petechias, 
passive hemorrhages, &c. Whatever the treatment adopted, however, 
these cases are too frequently fatal. 

Cold affusion has, at various times, been extolled by eminent prac- 
titioners,, but the plan has been only sparingly adopted. Some have 
recommended that it should be conducted in the manner laid down 
for scarlatina, while others confine themselves to sponging the surface 

1 See Lancet, vol. ii. 1841-2, page 441. 



ERUPTIVE FEVERS. 473 

of the body, or the face alone. Cold water does not appear to have 
the effect of causing retrocession of the pustules, but is thought to 
increase the congestion of the mucous membranes. My brother, Dr. 
Marris Wilson, has pursued the practice of sponging the surface for 
several years, and he assures me with the best success. 

The belladonna treatment recommended for scarlatina is also ap- 
plicable to small-pox. I have seen this remedy exhibited with benefit, 
both as a prophylactic and a curative measure. 

Vaccination has been observed to possess the power of modifying 
variola, even when an attack of the latter has commenced. Some 
remarkable cases are on record in which the good effect of this remedy 
was apparent ; and it recommends itself by its extreme simplicity. 
Eichhorn, who was the projector of the plan, inserted the vaccine 
lymph by forty or fifty incisions, immediately that the symptoms of 
small-pox became apparent. 

As regards local treatment, various plans have been adopted and 
recommended for the purpose of bringing the pustules to a" favorable 
issue, and preventing the deep ulcerations with their consequent 
cicatrices, which are apt to ensue when the eruption is left to itself. 
We will now proceed to consider these plans; but, before doing so, it 
may be necessary to premise that every precaution should be taken 
to prevent the rupture and laceration of the pustules by the nails of 
the patient, in efforts made to relieve the itching by which the desic- 
cating process is accompanied. The face should be frequently and 
well bathed with an infusion of poppies, or mallow, with weak barley- 
water, or a weak solution of common salt, particularly in the region 
of the eyes, nose, and lips. The secretions from these parts should be 
removed as much as possible by means of a sponge wetted with these 
fluids, and whenever an excoriation is formed, it should be anointed 
with a liniment composed of equal parts of olive oil and lime-water, 
or dusted with starch powder. But a better means of relieving the 
heat and dryness of the skin, and that state which conduces to itching, 
is by anointing the surface plentifully with the benzoated ointment 
of oxide of zinc. This should be applied pretty thickly, and repeated 
as often as it dries up or becomes thin from wiping or rubbing. The 
ointment will not interfere with the escape of secretions, or with the 
removal of such secretions when effused on the surface ; but will 
tend very considerably to the comfort of the patient, by keeping the 
inflamed skin soft and moist. Some fragments of tissue-paper pressed 
gently on the ointment will further contribute to the protection of 
the skin. 

The importance of keeping the surface moist, and excluding the 
atmosphere, would seem to have suggested to Ferdinand Hebra, the 
renowned dermatologist of Vienna, the application of his apparatus 
for maintaining a permanent warm bath, to cases of small-pox. A 
butcher's apprentice, eighteen years of age, seized with confluent 
variola, was placed in the bath on the fifth (lay of invasion, and just as 
the eruption was in course of development; and retained there until 
the seventeenth day, when the crusts had fallen. Hebra expresses 
his satisfaction at the result of the experiment, although, during his 



474 DISEASES FEOM UNKNOWN ANIMAL POISONS. 

confinement in the bath, the patient was attacked with pleuro-pneu- 
monia dextra, nevertheless, as far as the variola was concerned, the 
fever remained moderate, and the eruption passed favorably through 
its course. I should be sorry to prejudge this method of treatment ; 
but I am disposed to regard it less favorably than the treatment by 
the sesquicarbonate of ammonia, with the local application of some 
material which shall form a coating to the skin, capable of excluding 
the air and possibly the light, and at the same time of maintaining a 
permanent state of moisture by retaining the evaporated fluids of the 
cutaneous surface. 

Great benefit is derived from pursuing the practice of the Arabian 
physicians, namely, opening the matured pustules, gently pressing 
from them their contents, and removing the latter by means of a 
sponge moistened with plain water, or with an infusion of poppies. 
This plan accelerates very materially the healing of the ulcerations, 
and prevents the formation of deep and disfiguring cicatrices. 

Various ectrotic 1 methods of arresting the development of the 
eruption of variola, and, consequently, of preventing the occurrence 
of cicatrices, have, from time to time, been suggested and employed. 
Nitrate of silver has been used for this purpose by Serres, Bretonneau, 
and Velpeau. If the apex of each conical vesicle be removed, and 
the pointed extremity of a stick of nitrate of silver inserted into 
the opened vesicle, its further progress will be instantly arrested. 
But this proceeding is necessarily attended with pain, and requires 
time for its performance. To obviate these objections, it has been 
proposed to paint the entire surface with a solution of nitrate of 
silver, containing fifteen or twenty grains to the ounce ; this applica- 
tion to a surface of any extent has been found to be dangerous, in 
consequence of giving rise to a considerable increase of the febrile 
symptoms, while the anticipated effect of checking the progress of 
the eruption has only partly succeeded. Moreover, the solution 
forms a mask to the part upon which it is applied, beneath which the 
pustules advance unseen and unaltered. The nitrate of silver as an 
ectrotic remedy is only available, therefore, for the eruption situated 
upon the face and neck, and to this it must be used quite at the 
outbreak of the disease, namely, on the first or second day, otherwise 
it will be liable to failure. In summing briefly the objections to the 
employment of nitrate of silver, they may be stated as follows: 
firstly, it creates pain ; secondly, it requires more time for its applica- 
tion than the practitioner can devote; and, thirdly, it augments the 
febrility and nervous exhaustion of the patient. 

Another ectrotic remedy has been warmly eulogized by Dr. Midi- 
vaine, 2 of Ghent. It consists in the application of sulphur ointment, 
by means of slight friction, to the entire surface of the skin. This oint- 
ment should be composed of two drachms of sulphur to an ounce of 
lard, and used three times a day, at as early a stage as possible of the 
disease. The effects of the remedy, according to Dr. Midivaine, are, 
contraction and hardening of the papulae, diminution of tumefaction 

1 'EKTirplo-Kity, to render abortive. 2 Bulletin de la Soc. Med. de Gand, 1840. 



ERUPTIVE FEVERS. 475 

of the skin, and subsidence of the gastro-intestinal irritation. The 
appetite of the patients quickly returns, and they are speedily 
restored to health. 

A more important ectrotic remedy than either of the preceding is 
one which was made the subject of an essay, 1 read before the Parisian 
Medical Society, by their President, Sir Joseph Oliffe. This remedy 
is mercury, applied to the external surface of the body, and is one 
which is deserving our most attentive consideration. Mercury 
administered internally has long been known to possess remarkable 
powers in modifying the influence of variola upon the system, but it 
was left to modern times to prove that this agent has also the pro- 
perty of neutralizing the variolous virus when applied externally. I 
pass over the well-known and unmeaning experiment of Von Wenzel, 
namely, the trituration of the variolous matter with calomel, and the 
subsequent marvel that the virus should have lost its inoculating 
power, to the more rational experiments of Serres, afterwards so suc- 
cessfully pursued by Briquet. The mercury was employed by these 
gentlemen in the form of a plaster, the emplastrum vigo cum mercurio, 
of which the formula in the French pharmacopoeia is as follows : 

R. — Mercury, 95 parts. 

Balsam of storax, ....... 48 

Common plaster, 312 

Wax, resin, turpentine, ana, . . . . . 16 

Gum ammoniac, bdellium, olibanum, and myrrh, ana, 5 

Saffron, 3 

Spirit of Lavender, 2 M. 

In the first experiment, a strip of this plaster was placed on the 
arm of a patient attacked with variola, while a similar strip of 
diachylon plaster was applied to the opposite arm. Under the mer- 
curial plaster the development of the eruption was arrested ; under 
the other plaster no modification took place. In a second case, the 
face of the patient was " covered with the plaster, a part of which he 
tore off during the night which followed its application. The denuded 
surface was the seat of suppurating pustules, whilst on that portion 
of the visage which continued subjacent to the plaster, their abortion 
was effected." In a third case, a man affected with " violent confluent 
variola, the pimples were small, scarcely raised above the level of the 
epidermis, and surrounded with a brilliant red areola. The vigo plaster 
was applied, and allowed to remain seven days ; on its removal, it Avas 
found that no suppuration had been established, with the exception 
of four pustules, and these were situated near the mouth, and had not 
been in contact with the plaster. This patient was radically and 
rapidly cured, and no scars were manifested." 

The mode of application of the mercurial ectrotic is thus stated by 
Sir Joseph Oliffe : " The whole face should be covered with a mask of 
the vigo plaster, merely leaving a space for the mouth, nostrils, and 
eyes. A little mercurial ointment is applied to the eyelids." "The 
plaster is allowed to remain for three days in simple small-pox, and 
for four in confluent." In the event of any objection to the plaster 

1 Lancet, vol. i. 1840-41, p. 674. 



476 DISEASES FROM UNKNOWN ANIMAL POISONS. 

arising, mercurial ointment may be substituted with a fair prospect of 
benefit. I recently suggested this plan of treatment to a young prac- 
titioner who had several cases of small-pox under his care ; he reported 
to me that within half an hour of applying the unguentum hydrar- 
gyri fortius to the skin, the troublesome itching was entirely stopped 
and the pustules ceased to grow. Serres entertained the belief that 
the mercurial treatment would effect the miscarriage of the eruption, 
at whatever period it was used ; but Briquet has satisfactorily shown 
that the eruption remains unmodified, if it have reached its pustular 
stage. The proper period for the application of the remedy is the 
second day, or, at the latest, the third day of the eruption. Its effect 
is to produce immediate resolution of the eruption, or to arrest it at 
the papular or vesicular stage ; it never becomes purulent, and the 
skin between the pustules is never inflamed and swollen. But, how- 
ever powerless as a perfect ectrotic the mercurial application may be 
when used in the pustular stage, it would seem, from the evidence of 
Sir Joseph Oliffe, that the local inflammation is much modified and 
ameliorated. According to Briquet, "the mercury acts as an anti- 
phlogistic, or resolutive, in destroying or suppressing the local inflam- 
matory process ; or it exercises a specific action on the cause, what- 
ever it be, which produces the variolous pustule." From his re- 
searches on other inflammations of the skin, the latter of these proposi- 
tions would appear to be the most correct. 

It is interesting to learn, that in the progress of his experiments, 
Briquet ascertained that mercury possessed precisely the same 
influence over vaccinia as over variola, an additional fact in evidence 
of the identity of these diseases. 

The mercurial ectrotic treatment has been adopted with success by 
Dr. Hughes Bennett, in Edinburgh. He employed an ointment con- 
sisting of the unguentum hydrargyri fortius, an ounce, mixed with one 
drachm of starch powder. The ointment was applied pretty thickly 
over the face night and morning, with the result of preventing itching 
and swelling of the skin, the deep red stains which small-pox com- 
monly leaves behind it, and the formation of pits. In the instance of 
two sisters, in whom I employed a similar means, all irritation and 
discomfort of the skin was prevented ; but symptoms of salivation 
showed themselves in the course of a few days, the mouth was tender, 
and the salivary glands enlarged and painful. If the same beneficial 
result could be obtained Avithout the mercury, the discovery would be 
of much importance. 

I have not heard of any injurious effects following the use of the 
mercurial ectrotic, but M. Piorry has recommended in its stead the 
application of blisters. The advantages of his method he conceives to 
be the avoidance of any risk of salivation, and of the danger of repul- 
sion. The blister, he remarks, is derivative in its action, and not re- 
pellent ; but he, at the same time, admits the possibility of ischuria as 
a consequence of its use. 

I cannot recognize for a moment the doctrine of repulsion, or the 
theory upon which it is based, in connection with the arrest of the 
serious effects of small-pox upon the face ; the only part of M. Piorry 's 



ERUPTIVE FEVERS. 477 

objection which merits attention is the chance of exciting salivation, 
which is known to be an occasional normal accompaniment of the 
variolous fever. If this fear should sway the mind of any of my 
readers, and if salivation, on the one hand, and ischuria on the other, 
should seem to them to prohibit the use of both remedies, there is 
another, against which neither objection holds ; although I believe 
it to be inferior in power to the mercurial ectrotic. I allude to the 
tincture of iodine. This fluid is to be pencilled on the eruption, 
at as early a stage as possible, once or twice a day. Dr. Crawford, 
of Montreal, first called attention to the remedy, in 1844, and gave 
a favorable report of its success ; and his report has been cor- 
roborated by the subsequent practice of other medical men in British 
America and the United States. Its good effects are, the alleviation 
of inflammation, pain, swelling, and itching, the arrest of development 
of the pustules, the prevention of the red stains which follow the 
eruption, and the considerable reduction in extent of the pitting of 
the skin. In this latter respect, the tincture of iodine is decidedly 
inferior to the mercurial ectrotic. 

The impermeability, tenuity, transparency, and simplicity of appli- 
cation of collodion, have given it a place among the substances 
which, acting upon the property of excluding air, have been employed 
as ectrotic remedies. It possesses the advantages of extreme clean- 
liness, and of enabling the operator to see what is passing beneath, 
without requiring to disturb it. Another of its properties, namely, 
its. contractility, must also be considered as an agent in its beneficial 
effect, since by means of the peculiar pressure which it exerts upon 
the skin, it will disperse the congestion of that tissue. Being 
incapable of producing ptyalism, it is free from any objection of that 
kind. It has been made the subject of experiment in France, and 
favorably reported on by Dr. Aran, of the hospital Bon Secours. 1 

The ethereal solution of mastich and iodine 2 of Dr. Thomas Smith 
Rowe, of the Margate Infirmary, would, with less iodine, probably be 
found to be an improvement on the tincture of iodine or collodion, 
and to combine the properties of both. 

An impression subsisted among the ancient physicians, that the 
light of the apartment in which small-pox patients are kept should be 
either modified or excluded. In pursuance of this view, and at the 
suggestion of John of Gaddesdcn, the rooms were hung with scarlet 
cloth, and the windows carefully blocked up. So recently as 1832, 
Dr. Picton, 3 of New Orleans, asserts, that in his practice no instance 
of pitting after small-pox occurred when the light was shut out. 
Serres placed a glass capsule over a small-pox pustule, and observed 
the effects produced by excluding the air and light. He found that, 
in proportion to the exclusion of both was the development of the 
pustule checked, and that when they were completely shut out, the 
pustule became shrivelled and quickly dried up. Moreover, Serres 

1 Bulletin de Th6rapeutiqne, vol. xxxix. p. 369. 

2 Vide "Selected Prescriptions." 

s American Journal of Medical Science. 



478 DISEASES FROM UNKNOWN ANIMAL POISONS. 

remarks that he never reaped such successful results, in the cure of 
small-pox, as he did at La Pitie, during one year that the patients 
were placed in a kind of cellar, which was very dark, and ill-ven- 
tilated. The same principle has been more recently acted on by M. 
Legrand, who proposed to the Academy of Medicine, in 1839, the 
plan of covering the surface of the body with gold leaf. After the 
experiments of M. Fourcault (page 79), this practice would appear 
somewhat hazardous. 

VARICELLA. 

Syn. Modified Small-pox. Varioloid. Spurious Small-pox. Variolce 
pusillai ; verrucosa? ; crystallines. Variola lymphatica. Verole volante. 
Fran. Unachten Kindpocken. Germ. 

During the prevalence of an epidemic of small-pox, the variolous 
contagion develops itself in a variety of forms, some of which are 
remarkable for their severity, and others for their exceeding mildness. 
A medium state between these two extremes has been denominated 
benignant small-pox. Upon closer investigation, it is perceived that 
benignant small-pox, and all the most serious varieties of this disease, 
are characterized by the appearance of eruption pursuing a given 
course within a given space of time, and presenting a regular 
succession of alterations. On the other hand, it is likewise perceived 
that there are several forms of eruption resulting from the same 
variolous contagion, which are deficient in the characters needful for 
their consideration with the preceding group. They are much milder 
in their local, and, for the most part, in their constitutional nature, 
and their course is limited to a shorter period. It is to this second 
group that the term varicella (modified small-pox) properly applies, and 
under this head I shall proceed to describe the different varieties which 
small-pox, in its modified form, is capable of assuming. 

Variola, it has just been observed, occasionally appears in its vari- 
cellar form without any obvious cause, the modification probably 
depending upon some present state of constitution of the individual. 
Thus, it not unfrequently happens that a single member of a family 
may be affected by varicella, while several others of the same family 
have true variola. But the individual so affected with varicella in 
this instance may, during a future epidemic, be attacked with genuine 
small-pox. At other times, and these are the most frequent, the 
eruption is modified by that state of constitution which succeeds 
to vaccination, inoculation, or a sporadic attack of small-pox. Hence, 
after the preparation of the system by either of these affections, the 
contagion of variola gives rise generally to varicella, and but rarely 
to the genuine small-pox. If other proof were needed of the close 
relation subsisting between variola and varicella, it would be found 
in the fact that the latter is infectious and contagious, and is capable 
of communicating true variola to a sound person. 

Varicella, in this point of view, may be regarded as an arrest of 
development of variola, and the forms which it is capable of assuming 
may, consequently, be deduced from the observation of the natural 
course of small-pox. Thus, if the variolous disorder were to expend 



ERUPTIVE FEVERS. 479 

itself in its first stages, we should have a varicella resembling the 
papular eruption of small-pox, in other words, a papular varicella ; if 
the variolous disorder progress beyond this stage, we shall then have 
a vesicular varicella; and if it proceed still further, & pustular varicella. 
The latter, however, is capable of presenting some modifications ; in 
one of these the contents of the conical vesicles are simply trans- 
formed into a purulent fluid, without any alteration of their form ; 
this constitutes the conical pustular varicella ; in another, the puru- 
lent fluid distends the vesicle to so great an extent that it presents a 
globular figure; this is the globular pustular varicella; while in a 
third the pustules assume the characteristic features of those of va- 
riola, being flattened and umbilicated ; this, which is the most ad- 
vanced grade of varicella, is the umbilicated pustular varicella. More- 
over, it has been remarked, that in varicella, as in variola, the consti- 
tutional affection may be present without the eruption, constituting 
varicella sine varicellis. 

It must not be supposed, however, that any one of these forms occurs 
singly ; the distinction is intended merely to apply to the general pre- 
dominance of one or the other, for each variety is more or less com- 
mingled with the rest, and, in some instances, all the forms appear upon 
the same individual in nearly equal proportion. In describing the va- 
rieties of varicella, it will be convenient to reverse the order of rela- 
tion here laid down ; thus, in a tabular plan, these varieties are — 

Pustular varicella : — Umbilicated pustular varicella, 
Globular pustular varicella, 
Conical pustular varicella. 

Vesicular varicella. 

Papdlar varicella. 

Varicella sine varicellis. 

A'aricella makes its invasion with symptoms resembling those of 
small-pox, but much milder in degree. In some instances they scarcely 
amount to more than mere indisposition, while, on the other hand, 
they may be severe. The chief of these symptoms are feverishness, 
uneasiness at the epigastrium, nausea, vomiting, pains in the loins and 
in the head, with accelerated pulse. At the end of a few days, 
usually three or four, the eruption makes its appearance in the form 
of red points and spots, which resemble those of small-pox. The 
constitutional symptoms are relieved by the eruption, and gradually 
decline, The eruption, however, proceeds on its course, advancing, 
if it be of the pustular kind, quickly through the papular and vesi- 
cular to the pustular stage, arriving at its height by the fourth or fifth 
day, and then declining without any increase of the constitutional 
symptoms, and without the secondary or suppurative fever which 
occurs in small-pox. The pustules speedily dry up and form thin 
brownish scabs, which fall in another few days, and leave but a slight 
and transient pitting of the skin, with a few discolored red or purplish 
spots. When, however, the pustules arc broken and lacerated by 
scratching, cicatrices of small size occasionally result. Varicella in 



480 DISEASES FROM UNKNOWN ANIMAL POISONS. 

its progress, is accompanied by a broad and patchy areola of a pale 
red color, which contracts its boundaries as the pustule advances, and 
ultimately forms a narrow, brownish circle ai-ound its circumference. 
The urine in varicella, when the fever is mild, differs very little from 
the normal state of that secretion. " Schonlein states, that in the 
first stage of this disease the urine is often as limpid as in hysteria." 
While "in a case of varicella, in which the early symptoms were ex- 
tremely severe, the urine was passed in very small quantity, of a deep 
red color, and a specific gravity of 1.022-7." 1 

UMBILICATED PUSTULAR VARICELLA, 

Syn. Varioloid. Modified small-pox. Varicella cellulosa, Cross. 

The precursory symptoms of this variety of modified small-pox usu- 
ally continue for three or four days, and are succeeded by an eruption 
of red spots, which soon become hard and papular in the centre. On 
the second day of eruption the papulae are conical in form, and vesi- 
cular at their points. On the third and fourth days the vesicles in- 
crease in size, and become flattened and umbilicated, while their con- 
tents lose their transparency, and assume an opaque and whitish hue. 
During the fifth and sixth days the suppurative stage is established, 
but without secondary fever, and the pustules on the face desiccate and 
form scabs. On the seventh day desiccation occurs on other parts of 
the body, and by the eighth the whole of the pustules are covered with 
yellowish-brown scabs, which, in a few days more, are detached and 
fall off. The process of desiccation commences at the centre of the 
pustule, and proceeds towards the periphery, and the scabs at their 
fall leave a slight pitting, and red or livid discoloration of the skin, 
which lasts for a few weeks, but no cicatrices or permanent impres- 
sions remain behind. 

Umbilicated pustular varicella is generally commingled with the 
conical and globular forms of the eruption, and also with the papular 
and vesicular kinds. It sometimes appears in successive eruptions, 
and in this case it is not uncommon to find on the skin, at the same 
time, papulae, conical vesicles, with their thin scabs ; and conical, glo- 
bular, and umbilicated pustules, with their thicker and browner scabs. 

VARICELLA GLOBULARIS. 

Syn. Gclobular varioloid. Hives. 

The globular variety of varicella is characterized by the form and 
large size of the pustules, which surpass those of all the other vari- 
cellse. At its height the dome of the pustule is larger than its base, 
which it consequently overhangs, and the latter is not quite circular 
in outline. The precursory symptoms of this variety are usually se- 
vere. They are succeeded by the eruption of a number of red spots, 
having in their centre a small, prominent, and globular papula, which 
speedily increases in size and becomes vesicular at its summit. On 

1 Simon, vol. ii. p. 282. 



ERUPTIVE FEVERS. 481 

the second or third day of the eruption, the contents of the vesicles 
assume an opalescent and pearl-white color, particularly towards the 
centre. On the fourth and fifth days, the vesicles go on increasing in 
size, the contained fluid becomes purulent, and the areolae, by which 
their bases are surrounded, of a bright red color. On the sixth the 
vesicles attain their greatest bulk, their contents are more purulent, 
and the areolae still further increased in redness. On the seventh and 
eighth days they begin to diminish, their parietes are flaccid and 
wrinkled, and desiccation is established. On the ninth day the desic- 
cation of the pustules is completed on the greater part of the body, 
and they are converted into brownish fcimellated scabs, which are 
loosened and thrown off during the two or three succeeding days, 
leaving behind them some slight impressions, and a temporary conges- 
tion of the derma. 

Globular varicella is not unfrequently mingled with the pustules of 
the umbilicated and conical varieties. The ordinary duration of this 
eruption is ten or twelve days, but if the pustules be developed succes- 
sively it may be continued for a few days longer. 

VARICELLA CONIFORMIS. 

Syn. Conical varioloid. Swine-pox. 

The conical variety of varicella is recognized by the form of its 
pustules ; they are developed, like the preceding, after two or three 
days of constitutional symptoms, upon red spots, which soon become 
papulated in the centre, and surmounted by whitish and opaque 
elevations of the epidermis. During the third day the size of the 
vesicle is increased, its form has become more distinctly conical, and 
its base more highly inflamed. During the fourth and fifth day, the 
vesicles still further augment in bulk, their contents become purulent, 
and the areola which surrounds them more inflamed. On the sixth 
day, they are flaccid and wrinkled, and begin to desiccate ; and on 
the seventh are covered by prominent scabs of a yellowish, or yellow- 
ish-brown color, which fall in the course of a few days. The pustules 
,of conical varicella are sometimes very numerous, and collected into 
closely set clusters; they are usually attended by considerable pru- 
ritus, and are not unfrequently intermingled with the pustules of the 
umbilicated variety. The ordinary duration of the eruption of vari- 
cella coniformis is eight or ten days, but when it occurs in successive 
attacks, it may be continued for a few days longer. 

"When the vesicles are torn and broken in attempts made by the 
patient to relieve the itching, the spots become inflamed, they ulcerate, 
and secrete a thick pus, which concretes into scabs of a greater thick- 
ness than those of the natural pustules. These scabs are of a dark 
hiown, or blackish color, they remain longer than the thinner scabs 
of the pustules, and leave cicatrices at their fall. Such accidents occur 
most frequently upon the face. 



482 DISEASES FROM UNKNOWN ANIMAL POISONS. 



VARICELLA VESICULAEIS. 

Syn. Varicella lentiformis, Willan. Varicella lympliatica. 
Chicken-pox. 

Vesicular varicella, or chicken-pox, is preceded by febrile symp- 
toms, which are very mild in the discrete form of the eruption, but 
severe in the confluent kind. The eruption makes its appearance in 
the form of small, red, and slightly raised spots, of an oval or irregular 
form. On the second day, a minute transparent vesicle is developed 
in the centre of each of the^e spots. On the third day, the vesicles go 
on progressively increasing; they are flattened on their summits, and 
the contained fluid, transparent and limpid at first, becomes yellowish, 
opaque, and lactescent. On the fourth day they begin to collapse 
and shrivel, and on the fifth and sixth, to desiccate into thin, brownish. 
and lamellated scabs, which fall on the eighth or ninth day, leaving 
behind them a slight congestion of the derma, but no depression. 
While this course is being pursued by the vesicles which first appear, 
others are successively developed, so that the eruption may be seen 
at once in all its stages, and may be prolonged to ten or twelve days, 
and sometimes to two or three weeks. The eruption of chicken-pox 
appears first on the back, and thence extends to the rest of the body : 
it is attended with much itching, and many of the vesicles retain their 
papular or aborted form ; the perfected vesicles are surrounded by an 
inflamed areola of small extent. 

VARICELLA PAPULARIS. 

Syn. Varicella verrucosa. Horn-pox. Variola? verninosoi ; verrucosa?. 

This is the most simple, and, at the same time, the least severe form 
of varicella. After the invasion of febrile symptoms of the mildest 
kind, an eruption of red spots, followed by papulae, is developed on 
the surface of the skin. The papulae are various in point of size, and 
hard to the touch, but they oifer no disposition to proceed to the 
evolution of vesicles and pustules. The redness fades in the course 
of a few days, and the papules are gradually lost. The eruption of 
papular varicella rarely exists alone ; it is usually commingled with 
one or other of the more advanced varieties. 

VARICELLA SINE VARICELLIS. 

Varicellar fever, occurs chiefly in those who have been inoculated 
or vaccinated, or have previously suffered from variola. It is occa- 
sionally, though rarely, observed during the prevalence of epidemic 
variola. 

Diagnosis. — Varicella differs from small-pox in several essential 
particulars, namely, in the lesser degree of severity of the constitu- 
tional symptoms ; in the shortness, of course, of the eruption; in the 
absence of secondary fever; in the appearance of the eruption at its 
height; in the minor degree of inflammation surrounding the pustules; 



ERUPTIVE FEVERS. 483 

in the thinness of its scabs ; and in its freedom from permanent im- 
pressions and cicatrices. 

At the earliest moment of eruption, it is impossible to establish a 
distinction, since both affections are developed in the form of red spots 
with central stigmata. 

Causes. — Varicella originates in the variolous contagion, and fre- 
quently precedes or follows an epidemic of small-pox. This observa- 
tion would lead to the inference that, at the commencement, the 
variolous contagion had not yet gathered sufficient power to excite 
true small-pox in any but the most susceptible, and that, at the con- 
clusion of the epidemic, the contagion had" lost the strength necessary 
to awaken any but a modified affection. The inference, in truth, is 
correct ; for when in a state of dilution, the variolous contagion is 
capable of producing only varicella in persons of average suscepti- 
bility. In those who possess the susceptibility of infection in a high 
degree, true variola may be excited ; and for the same reason, the con- 
tagion of varicella is apt to communicate variola to individuals so 
constituted. Another condition conducive to the development of 
varicella is deficient susceptibility. In some instances, this deficiency 
is the result of constitutional idiosyncrasy ; in others, and they are the 
most usual, it is the consequence of a modification of the system, pro,- 
duced by vaccination, by inoculation, or by a previous attack of 
variola. 

Varicella is infectious and contagious, and transmissible by inocu- 
lation. Its contagion may excite either varicella or true small-pox. 
The result of inoculation is similar ; in one instance varicella may be 
developed ; in another," true variola. The variola communicated by 
varicella is for the most part mild, but the severity of the affection 
would appear to depend upon the constitution of the individual, 
rather than upon the nature of the contagion. Varicella may occur 
repeatedly in the same person, and it possesses less preservative power 
against the contagion of small-pox than vaccination. 

Vesicular varicella, or chicken-pox, is stated to have occurred as an 
epidemic, and independently of variola; Dr. Mohl 1 observes, that, at 
Copenhagen the chicken-pox occurred annually between the years 
1809-1823, without any association with small-pox. And Dr. Watson 
remarks, " It must, therefore, I think, be admitted that there is a 
separate disease called chicken-pox, which springs from a specific 
poison." Vesicular varicella is less easily transmissible than the 
other forms. When inoculated, varicella of the same kind is some- 
times developed, at other times the pustular form, and again, true 
small-pox. 

PROGNOSIS. — Varicella is generally a mild disease, and one of favor- 
able termination. Sometimes, however, it issues fatally, and during 
certain variolous epidemics, is remarkable for the severity of its con- 
comitant symptoms, orfor a fatal tendency. The umbilicated pustular 
Varicella is tin' most serious of its varieties. 

TREATMENT. — The treatment of varicella is to be conducted on the 

1 De Varioloid ibus et Varicellis. 



484 DISEASES FROM UNKNOWN ANIMAL POISONS. 

same principles as that of variola. If there be congestions, they must 
be combated as they arise ; and if the eruption should recede, it must 
be re-excited by stimulation of the skin. In ordinary cases, the sim- 
plest antiphlogistic management is all that is needed. 



VACCINIA. 

Syn. Variola vaccina. Variolce vaccines. Cow-pox. Cow small-pox. 

Variola vaccina, the small-pox of cattle, is a contagious inflammation 
of the skin, prevalent among cattle, and occasionally communicated to 
man. It is characterized by the development, upon inflamed bases, 
of multilocular and umbilicated vesicles, which pass by degrees into 
the pustular form, and terminate in hard, dark-brown scabs, the latter 
leaving behind them deep and permanent cicatrices. Variola vaccina 
is accompanied by constitutional symptoms, which are mild during the 
first stages of the vesicle, but become more severe, and constitute a 
secondary fever, when the local inflammation arrives at its height, and 
the suppurative process is about to be established. 

The existence of a disease identical with small-pox among the infe- 
rior animals, is a theorem that might, a priori, be predicted. It is 
perfectly consistent with our knowledge of the physiological laws, 
and comparative structure of man and animals. It is a position well 
established with regard to some other diseases, and there can be no 
doubt that still further analogies in relation to pathology will be 
unveiled by future research in that most interesting department of 
medical science. The announcement of the discovery of a disease 
analogous to small-pox in the cow, in the horse, or in any other 
animal, at the present day, would occasion little surprise ; it is 
admitted, indeed, as a principle, in the first rudiments of our physio- 
logical education; but when this declaration was made in 1796 by 
the immortal Jenner, it was a bold soar of genius, and too enlightened 
for the philosophy of his age. It is now, however, well established, 
that small-pox has for centuries been prevalent among animals in all 
parts of the world ; that it has made its invasion as an epizootic, and, 
for the most part, in connection with a similar pestilence among men. 
Jenner was acquainted with the fact of the occurrence of a disease in 
the horse, which was communicable to the cow, and capable of engen- 
dering in the latter animal an eruption that could not be distinguished 
from the true vaccinia. This disorder in the horse was, unquestion- 
ably, the equine small-pox ; it was, however, from the circumstance of 
its development in a situation where, from the thmness of the skin, 
eruptive disease in a mild form would most naturally occur, namely, 
iu the heels, confounded with a more common disease of that region, 
the (jrease. By a wrong inference drawn from this observation, an 
inference perfectly natural and perfectly excusable in the state of sci- 
ence at that period, an inference which its distinguished author subse- 
quently relinquished, namely, that the variolas vaccinae had their origin 
in the horse, Jenner created an argument which, for many years, was 
industriously employed as an objection to the philosophy of his 



ERUPTIVE FEVERS. 485 

views ; with how little injury to the splendor of his discovery, we who 
live can tell. 

In the excellent report 1 of the Vaccination Section of the Provincial 
Medical Association, the committee remark that the ravages of this 
epizootic are not confined to one region of the earth; that such as it 
has been seen in the valleys of England, it has likewise been observed 
upon the mountains of the Andes, on the elevated ranges of the Hima- 
layas, in the plains of Lombardy, in the green pastures of Holland, 
and on the sunny slopes of Asia. It is interesting, moreover, to 
learn, that in Bengal the natives apply to this disease the self-same 
appellation that they give to the small-pox in the human subject, 
namely, bussunt, mhata, or gotee. It would be so much out of place, 
in a work dedicated to practical purposes, to go into the numerous in- 
quiries and arguments that have been raised upon the question of the 
history and analogies of cow-pox, that I shall content myself with stat- 
ing the facts which I conceive to be established relative to this disease, 
and the principal observations by which those facts are supported. 
The facts to which I allude are — 

1. The prevalence, at the same period, of the cow-pox among cattle, 
and the small-pox among men. 

2. The transmission by contagion of the small-pox to cattle, and the 
consequent development of cow-pox in those animals. 

3. The transmission by inoculation of the small-pox to cattle, and the 
consequent development of cow-pox in those animals. 

4. The transmission by contagion of the cow-pox to man, and the 
consequent development of a pustule similar in character to the vaccine 
pock of the cow. 

5. The transmission by inoculation of the cow-pox to man, and the 
consequent development of a pustule similar in character to the vaccine 
pock of the cow. 

6. The transmission by inoculation of the cow-pox to man, and the 
consequent development of an eruption similar to, if not identical with, 
small-pox. 

The first of these theorems appeals to history for its proof, and is 
additionally substantiated by the facts which tend to support the 
second proposition. Its accuracy has been verified also by several 
practitioners during the recent epidemic of small-pox in England. 
Mr. Gibson, 2 in a sketch of the province of Ghizerat, states that variola 
carries off annually many persons, and "the same disorder is at times 
\<iv fatal among the cattle." Mr. Macpherson, writing from Murshi- 
dabad in 1 S:J(>, observes, that the disease among the cows has not 
occurred in that province for two years; that during the same interval 
very few cases of variola have been known, and from these circum- 
stances he infers "that the unknown causes which favor the disease 
in the human subject have the same tendency in the cattle; in fact, 
the variola, and mhata or gotee, owe their origin to the same cause." 
Mr. Lamb, Stationed at Dacca, remarks, in 1836, that during the 

1 Transactions oftlie Provincial Medical Association. Vol. viii., 1840, p. 1. 

2 Transactions of tin; Medical and Physical Society of Bombay. Vol. i. 



486 DISEASES FROM UNKNOWN ANIMAL POISONS. 

prevalence of variola, the cow-pox "appeared in one muhalla, and car- 
ried off fifteen or twenty cows." 

The transmission by contagion of the small-pox to cattle, which 
rests upon the assertion of numerous observers, is strikingly illustra- 
ted by Mr. Ceeley, 1 in the following narrative : " On Friday, the 
twenty-second of October, 1840, my friend Mr. Knight informed me 
by letter, that he had on that day seen on the hand of a patient, Mr. 
Pollard, aged fifty-six, who had never had small-pox or vaccine, two 
broken vaccine vesicles, which the patient said he had caught while 
milking his own cows, some of which he knew were affected with the 
same disease, and were then very difficult to milk." Mr. Pollard at 
the same time expressed his conviction " that his cows had been 
infected from human small-pox effluvia, to which he considered they 
had been exposed." It appears that the small-pox had been prevalent 
in the village of Oakley, and the last three persons attacked were two 
women and a child. " The two cottages in which these three patients 
resided during their illness were situated on each side of, and closely 
connected with, a long narrow meadow, or close, comprising scarcely 
two acres. The first-named patient, though thickly covered with 
pustules, was not confined to her bed after the full development of the 
eruption, but frequently crossed the meadow to visit the other patients, 
the woman and child, the former being in great danger with the con- 
fluent and malignant form of the disease. She died on Monday, the 
seventh of September, and, according to custom, was buried the same 
evening. The intercourse between the cottages across the close was, 
of course, continued after this event. On the following day the wearing 
apparel of the deceased, the bedclothes, bedding, &c, of both patients, 
were exposed for purification on the hedges bounding the close, the 
chaff of the child's bed was thrown into the ditch, and the flock of the 
deceased woman's bed was strewed about on the grass within the close, 
where it was exposed and turned every night, and for several hours 
during the day, until the thirteenth of September, eleven days. On 
that day the above-mentioned eight milch cows and two sturks were 
turned into this meadow to graze. They entered it every morning 
for this purpose, and were driven from it every afternoon, to be trans- 
ferred to a distant meadow to be watered and milked, where they 
remained through the night. Whenever the cows quitted the meadow 
in question in the afternoon, the infected articles above-mentioned 
were again exposed on the hedges, and the flock of the bed spread out 
on the grass, and repeatedly turned, where it remained till the morn- 
ing, Avhen the cows were readmitted." It appears, however, that the 
removal of the infected articles was not always accomplished so 
punctually as had been enjoined, for both the proprietor and the 
milkers affirm, that on one occasion, at least, they observed the bed- 
flock on the grass, and the cows amidst it, and licking it up. The 
proprietor positively declares, and the milkers corroborate his state- 
ment, "that the animals were in perfect health on their first entering 
this close, but within twelve or fourteen days of that event, five of the 

1 Transactions of the Provincial Medical Association. Vol. x., 1S42, p. 211. 



ERUPTIVE FEVERS. 487 

milch cows appeared to have heat and tenderness of the teats, upon 
which, imbedded in the skin, were distinctly felt small hard pimples, 
which daily increased in magnitude and tenderness, and in a week or 
ten days rose into blisters, and quickly ran into brown and blackish 
scabs. At this period, when the teats were thus blistered and swollen, 
and very tender, the constitutional symptoms were first observed, 
viz., sudden ' sinking,' or loss of milk, dribbling of saliva from the 
mouth and frequent inflation and retraction of the cheeks, starring of 
the coat, 'tucking up of the limbs,' and ' sticking up' of the back, and 
rapid loss of flesh ; the process of milking was now very difficult, 
disagreeable, and even dangerous ; and on the fourteenth of October, 
the middle of the third week, the detachment of the crusts and loose 
cuticle, and the abundant discharge of pus on attempting to milk, 
compelled the milkers to desist, for the purpose of washing their hands. 
Soon after this period, the cows became by degrees more and more 
tranquil, as the tenderness and tumefaction of the teats subsided, and 
finally, milking was performed with comparative facility, and at the 
period of our visit, scarcely any trouble arose in the performance of 
the operation, though here and there a teat seemed still tender." In 
his remarks upon this case, Mr. Ceeley observes, " Another circum- 
stance, too, requires to be particularly noticed ; it is the fact of the 
occurrence of the vaccine disease on a young sturk, which, of course, 
could not have been induced by those casualties which commonly 
propagate it among milch cows, but simply by the cause which origi- 
nated the disease in the other five animals, whatever that may have 
been. The sturk is not considered liable to the vaccine ; at least so 
it is inferred in this neighborhood, because no one has ever seen the 
animal affected by it." 

It is scarcely needful to add more evidence to that conveyed in the 
preceding paragraph, in proof of the communicability of the contagion 
of small-pox from man to cattle, but I cannot forbear quoting one or 
two further illustrations; the first is contained in the following brief 
extract from a letter addressed by Dr. Waterhouse, of Cambridge, 
Massachusetts, to the celebrated Jenner : " At one of our periodical 
inoculations," says the writer, " which occur in New England once in 
eight or nine years, several people drove their cows to an hospital 
near a. populous village, in order that their families might have the 
daily benefit of their milk. These cows were milked by persons in 
;ill stages of small-pox ; the consequence was, the cows had an eruptive 
disorder on the teats and udders so like the small-pox pustule, that 
every one in the hospital, as well as the physician who told me, 
declared the cows had the small-pox." Dr. Sunderland, of Bremen, 
communicated the small-pox contagion to cows, by covering them 
with sheets between which persons fatally affected with small-pox had 
lain. These experiments were successful in a few cases, after many 
trials. 

The third proposition, namely, the transmission of small-pox to 
cattle by means of inoculation, and the consequent development of 
COW-pos in those animals, is also established on abundant evidence, 
for the chief of which we are again indebted to the zealous perse- 



488 DISEASES FROM UNKNOWN ANIMAL POISONS. 

verance of Mr. Ceeley, of Aylesbury. It is stated by Dr. Macmichael, 
in an essay read before the College of Physicians in 1828, that " vac- 
cine matter having failed in Egypt, medical gentlemen were led to 
institute oertain experiments by which it has been discovered that, 
by inoculating the cow with small-pox from the human body, fine 
active vaccine virus is produced." M. Viborg, of Berlin, is reported 
to have inoculated cattle, and several other classes of domestic ani- 
mals, with success. 

Mr. Ceeley instituted a series of experiments on the inoculation of 
the cow with variolous lymph in the month of February, 1839. In his 
first subject, no effect was observed for nine days, at the end of which 
time, one out of seven punctures, inoculated with virus of the seventh 
or eighth day, presented the appearance of a tubercle. On the tenth 
day, this tubercle had all the characters of the vaccine vesicle ; by 
the fifteenth day the vesicle reached its acme, and was " truly splen- 
did." Decline commenced on the sixteenth day, the crust was well 
formed on the seventeenth, but was rubbed off prematurely. In this 
experiment the vesicle was retarded five days ; the usual period of 
maximum development of the variolo-vaccine pock being the tenth 
day. In a second experiment, the first inoculation failed. After 
reinoculation, four out of the seven punctures looked purplish or 
livid on the fifth day, and were vesicular, with incipient central 
crusts, on the sixth day. By the tenth day, they had attained their 
acme. On the eleventh, decline had commenced, and progressed 
gradually till the twenty-sixth day, when the crusts fell, leaving 
behind them smooth, rose-colored pits. 

The fourth proposition is one so well established as to require no 
especial remark. The nature of the affection resulting from this con- 
tagion is considered in the section entitled " Casual variolic vaccinas 
in man." The fifth proposition is equally satisfactory in its proof; 
the effects of "primary lymph" from the variola vaccinas will be 
stated at a future page. 

In support of the fact announced in the sixth proposition, it has 
been observed, that when the epizootic disease presented characters 
of great severity, the symptoms produced on man by inoculation from 
such cases were also severe, and often serious, contrasting strongly 
with the mild affection engendered by the virus from the ordinary 
discrete form of cow-pox. . Mr. Macpherson, in experiments with this 
virus in Bengal, in 1887, found that an eruption was developed, 
which was identical with small-pox. Mr. Wood, of Gowalpara, in 
1839, met with' similar eases of so great severity, that he was led to 
contemplate the substitution of inoculation with small-pox virus, as 
a safer expedient. At Silhet, Mr. Brown removed some dark-colored 
scab- from a cow laboring under variolous disease, and triturating 
tlu in in a mortar, he inoculated several children with the pulp. These 
cases exhibited nothing remarkable, excepting a somewhat greater 
degree of constitutional disturbance on the eighth day than usual. 
After two months, children inoculated from this stock were attacked 
on the eighth day with severe fever, " followed by an eruption, which 
spread over the whole body, and, in one case, proved fatal." The 



• ERUPTIVE FEVERS. 489 

eruption so produced bore all the characters of true small-pox. Thus, 
it would appear, that, as the small-pox virus, when introduced into the 
system of the cow, is so modified by the vital laws which regulate the 
functions of the animal as to produce an eruption of cow-pox ; so, on 
the other hand, the virus of the cow, under like circumstances, is 
modified by the constitutional phenomena of the human organism, and 
is made to assume the characters of small-pox. 

VARIOLA VACCINA IN THE COW. 

Variola vaccina in the cow is by no means a common affection, and 
when it occurs is usually met with in milch cows — a circumstance 
attributable to the transmission of the contagion by the hands of the 
milkers. Occasionally the disorder appears as an epizootic, but more 
frequently in the sporadic form. In rare instances it would seem that 
the source of this contagion has been a variolous eruption developed 
in the horse, and mistaken for a more common vesicular disease of that 
animal, the grease. The vaccine disorder is modified by a variety of 
conditions, such as the temperament of the animal, the tone of its tis- 
sues, its state of health, the thickness of its skin, and its color. A 
slight difference is also observed in the disease, in relation to its origin 
in a sporadic form, or as the result of contagion communicated by 
the hands of milkers ; the former of these varieties Mr. Ceeley terms 
natural, the latter casual. 

Natural variola vaccina makes its invasion with heat and tenderness 
of the teats and udder, unaccompanied by constitutional symptoms ; 
the inflamed surface is uneven, and pimply to the touch, and papulae 
of a red color, hard, and as large as a pea, are soon developed. In 
three or four days from invasion, the papulae have attained the size of 
a horse-bean ; they are tender and painful, and vesicles are gradually 
raised upon their summits. The vesicles, increasing in size, become 
acuminated, ovoid, or globular, and are distended with an amber-tinted 
and viscid fluid. When ruptured, they present depressed centres, with 
an elevated and indurated margin ; and when the epidermis is rubbed 
off, the surface of the corium is of a vivid red color, with a small cen- 
tral slough. When uninjured, or merely ruptured, without the removal 
of the epidermis, the vesicles desiccate into thick, dark-brown crusts, 
which commence in the centre, and proceed towards the circumference, 
appearing at first inlaid in the marginal elevation, and subsequently 
extending completely over it. The surface from which the epidermis 
is removed becomes covered by thin, brownish scabs, which are termed 
Scconiliin/. 

Casual variola vaccina appears as an eruption on the fifth or sixth 
day after contagion, in the form of small, tender papulae, which are 
developed upon the teats and neighboring surface of the udder. By 
the sixth and seventh days the papulae have attained the size of a pea; 
they are reddish in color, and circular or oval in form. On the sum- 
mit they become gradually depressed, assume a yellowish-white and 
pearly hue. and have a small central dot or linear impression. On 
the eighth or ninth day, the central concavity increases in depth, while 
the margin becomes more elevated, tense, and shining, more pearly or 



490 DISEASES FROM UNKNOWN ANIMAE POISONS. 

silvery in its aspect, and the central depression acquires a bluish or 
slaty tint. At this period the pock is more than half an inch in 
diameter, and is surrounded by a narrow areola of a pale rose, or light 
damask hue. Between the tenth and eleventh day, the eruption 
reaches its acme ; the elevations are now upwards of three-fourths of 
an inch in diameter, the areola has increased to four or five lines in 
breadth, and the integument beneath is tense and indurated. The 
central depressions have augmented in depth, their bluish, slaty color 
has acquired greater intensity, and the epidermis which invests them 
becomes distended with an abundance of lymph, and rises into a globular 
or conical vesicle. Many of these vesicles are now ruptured, others 
remain whole, but, in either case, they shrivel and desiccate into 
brownish or black crusts, which are first observed in the centre, and 
increase towards the circumference, until they reach and overlap the 
marginal border of the pock. The induration and enlargement of the 
latter diminish, and the crusts are thrown off spontaneously between 
the twentieth and twenty-third day, leaving a slightly depressed and 
smooth cicatrix, of a pale rose or whitish color. Such is the usual 
course of the cow-pock, but it necessarily presents many diversities 
of appearance, dependent upon aggravation of symptoms, &c. Thus, 
instead of forming crusts in the manner described, ulcerated and slough- 
ing surfaces are sometimes produced, which remain for weeks in an 
irritable state. Moreover, casual vaccine variola always presents the 
eruption in every stage of its progress at the same moment, the eleva- 
tions with their central depressions are intermingled with incipient 
papulae, and while the crusts are being perfected in some, the vesicles 
are yielding in others to the distension of their lymph. This succes- 
sion in the eruption depends upon the diffusion of the virus by the 
rupture of the vesicles, either in consequence of the movements of the 
animal, or by the milker, and the consequent revaccination of the 
neighboring unaffected skin. Mr. Ceeley has observed as many as 
sixty pocks upon the udder and teats of a single cow. 

VARIOLA VACCINA IN MAN. 

Variola vaccina may be communicated to man, either accidentall} T , 
or by voluntary inoculation. In the former case, the contagion is 
received directly from the animal, usually from the cow, but some- 
times, as in the case of variola equina, from the horse. It had long 
been observed, that persons who had suffered from this disease were 
preserved against the influence of small-pox, and thence originated the 
practice, introduced by Jenner, of transmitting the contagion artifi- 
cially to man, by means of inoculation. 

It is a principle, well established in pathological science, that the 
animal system, once subjected to the influence of any disease origin- 
ating in specific contagion, is protected, to a greater or less extent, 
against subsequent incursions of that disorder. Thus we observe that 
the modification which the system undergoes in the reception of 
rubeola and scarlatina, is protective of the individual against that 
contagion for the rest of life. The same circumstance is remarked 



ERUPTIVE FEVERS. 491 

with regard to small-pox and other contagious fevers. When this fact 
was contemplated by the medical philosopher, in association with the 
fearful ravages of that dreadful pestilence and scourge of the human 
race, small-pox, such as it existed in former ages, the expedient 
suggested itself to his mind, that if the disease could be anticipated, 
if the disorder, in a mild form, could be communicated to man, life 
would be spared, and the system equally defended against the subse- 
quent contagion of a more virulent and fatal disease. This design, 
happy in thought, and happy in application, gave birth to the practice 
of inoculation for small-pox. Inoculation for small-pox, however, was 
not free from objection; the disease thus engendered was always 
serious, often fatal, and frequently became the source of a malignant 
contagion. In this state of demi-subj ligation small-pox w y as found by 
Jenner, when the well-known fact of the protective influence of cow- 
pox first engaged his attention, and aroused in his comprehensive 
mind the philosophic thought that spread happiness and security where 
gloomy anticipations and uncertainty had previously prevailed. He 
had the talent to perceive in cow-pox, small-pox in its mildest possible 
form ; and he trusted that the transmission of this to man would insure 
the same results as inoculation with the virus of human small-pox. This 
trust was rewarded by the complete success which attended the prose- 
cution of his views. 

In the foregoing remarks I have endeavored to show that the 
advance of improvement to the Jennerian standard was progressive, 
and that it was created by the contemplation of the wants of the 
human race. Since Jenner's discovery, more than half a century 1 has 
glided away, half a century, moreover, replete with important and 
valuable discoveries, both in general and medical science. A portion 
of that half century has seen the attention of medical practitioners 
again engaged in considering the imperfections of our present means 
of defence against small-pox. A third era of discovery has dawned. 
It is seen that although, as a general rule, the principle announced in 
the preceding paragraph, namely, that the invasion of the contagious 
disease is protective against subsequent attacks of the same disease is 
correct, yet, that exceptions to this rule do occur so frequently, as to 
indicate the necessity for further investigation into the nature and 
history of small-pox, with a view to afford additional security against 
its ravages. Thus it has been observed, that secondary attacks of 
small-pox are not unusual, and that small-pox after vaccinia very fre- 
quently occurs. Instances of the latter kind, indeed, are so often met 
with, as to lead to the belief that vaccinia gradually loses its protective 
influence over the system. 2 

With a view to meet the declining influence of vaccinia, numerous 
propositions have been made, and modes of practice adopted, the 
principal of which are revaccination, retro-vaccination, variolo-vacci- 
nation, ;ind an immediate return to the variolic vaccinae of the cow. 

1 Jenner's Aral experiment was made on the I Ith of May, 179G. 

2 In ;i conversation which I recently had with Mr, Marson, he made the important prac- 
tical observation that, after an imperfect vaccination, revaccination will often fail, while 
the person still remains open to the reception of small pox. 



492 DISEASES FROM UNKNOWN ANIMAL POISONS. 

These various modes of re-establishing the protective powers of vac- 
cinia I shall examine in their turn, after having, in the first place, 
traced the history of the casual vaccinia, as observed and recorded by 
Mr. Ceeley, and having described the effects of ordinary vaccination 
with Jenner's lymph. 

CASUAL VARIOLA VACCINA IN MAN. 

The transition of the cow-pock contagion to man presents all the 
anomalies which are known to accompany exposure to other sources 
of contagion. Milkers who have never been vaccinated will some- 
times escape altogether, while others who have been vaccinated or 
variolated, will take the disease; and instances not unfrequently occur 
in which persons who regard themselves secure, in consequence of 
having previously suffered from casual vaccinia, are a second time af- 
fected. In all the three latter Cases, however, and especially in the 
last, the disorder is characterized by the manifestation of a much 
milder type than that of the unmodified disorder. The parts of the 
body usually affected in milkers are the backs of the hands, the flex- 
ures of the joints and sides of the fingers, and the face. When the 
eruption appears in the latter situation, the virus is conveyed by means 
of the hands moistened with the lymph of the ruptured vesicles. On 
the backs of the hands, and between the fingers, the epidermis is thin- 
ner than on the palmar surface, and consequently affords greater fa- 
cility to its imbibition by the dermal tissues. For it is satisfactorily 
proven, that abrasion of the surface is by no means necessary to the 
inoculation of the disease. When, however, the epidermis is abraded, 
and the skin chapped, the effects of the virus are remarkable for 
severity, subcutaneous abscesses are liable to form, and the lymphatic 
vessels and glands frequently become inflamed. 

The signs which indicate that the contagion has taken effect, are 
the appearance of inflamed spots or papulae, which are hard to the 
touch, acuminated, and deep-seated. The papulae are of a deep rose- 
red or purplish color, and are soon surmounted by an ash-colored 
or livid vesicle, which assumes the umbilicated character as it increases 
in size, and then becomes yellowish in the centre. At this period the 
areola makes its appearance, lymph is effused beneath the umbilicated 
epidermis, and a vesicle of variable size, and of a bluish or slate-colored 
aspect is developed. The local inflammation is sometimes so severe 
as to produce sloughing of the derma and serious constitutional dis- 
turbance. 

In illustration of this affection, Mr. Ceeley 1 has recorded the follow- 
ing interesting case : 

"Joseph Brooks, aged seventeen, a fine, healthy, intelligent young 
man, who had not been the subject previously of variola or of the 
vaccine, stated that he commenced milking on Friday, the ninth of 
October, and that his milking was confined to four cows, only one of 
which had the disease, from four to six vesicles on each teat. He 
milked these four cows occasionally, and continued to do so till the 

1 Transactions of the Provincial Medical Association, vol. x., p. 216. 



ERUPTIVE FEVERS. 493 

eighteenth of the same month (ten days), having milked them in that 
period six times. On this day (the eighteenth) he felt the cervical 
absorbent glands and lymphatics stiff and tender, and on the twentieth 
found a pimple on the temporo-frontal region, which he could not 
resist scratching. On the day before that he observed on his finger a 
red pimple, of the size of a pin's head; on the next day one on the 
thumb, very small. In neither situation was he aware of the pre- 
existence of any visible wound or abrasion of the cuticle. On the 
twenty-first he had headache, general uneasiness, and pains in the 
back and limbs, with tenderness and pain in the course of the cor- 
responding lymphatic vessels and absorbent glands, particularly of 
the axilla, which increased till the twenty-third, when • nausea and 
vomiting took place. His right eyelids became swollen, and were 
closed on that day ; but after this period he became better, in all 
respects, never having been confined to the house, although disabled 
from work. The vesicle on the temporal region had a well-marked 
central depression with a slight crust, a general glistening appearance, 
and was of a bright rose or flesh color, with a receding areola, and 
there was an inflamed, tumid, and completely closed state of the cor- 
responding eyelids. 

" On the finger the vesicle was small and flat, with a slightly 
depressed centre, containing a minute crust. It had a beautiful 
pearly hue, and was seated on a bright, rose-colored, slightly elevated 
base. On the thumb the vesicle was also flat and broad, but visibly 
depressed towards the centre, where there appeared a transverse 
linear-shaped crust, corresponding doubtless with a fissure in the 
fold of the cuticle. The vesicle was of a dirty, yellowish hue and 
visibly raised on an inflamed, circumscribed base; lymph was ob- 
tained from a vesicle on the temple, in small quantity, by carefully 
removing the central crust, and patiently waiting its slow exudation. 
In this, as in most other respects, it strikingly resembled the vesicle 
on the cow, and appeared as solid and compact. The lymph was 
perfectly limpid, and very adhesive. No lymph was taken from the 
vesicles on the finger and thumb, with a view to avoid any interrup- 
tion of their natural course. 

" On the twenty-sixth and twenty-seventh, when the redness and 
elevation of the base of the vesicles had materially diminished, the 
vesicles themselves had become greatly enlarged. On the thumb and 
finger they were loosely spread out at the circumference, each having 
;i dark and deep central slough. On the temple, the margin of the 
vesicle, as on the cow, was firm and fleshy, its diameter being nearly 
ten lines, and its centre filled with a dark brown firmly adherent 
slough. In about seven or eight days, by the aid of poultices, the 
sloughs separated, and the deep ulcers healed, leaving cicatrices, like 
variola, deep, puckered, and uneven, which were seen on the twenty- 
fifth of November." 

INOCULATED VARIOLA VACCINA. 
The inoculation of variola vaccina, or, as it is popularly termed, 
vaccination, consists in the transference of a small portion of the con- 



494 DISEASES FROM UNKNOWN ANIMAL POISONS. 

tents of the vaccine vesicle, the vaccine lymph or virus, to the papillary 
surface, or to the tissues of the derma of*i sound person. This object 
is effected by means of a small puncture, by several punctures, by a 
number of superficial scratches, with the point of a lancet or needle 
imbued with the virus ; or, as recommended by Mr. Crosse, 1 by means 
of a small blister. The blister is produced by retaining upon the arm 
a piece of adhesive plaster, in the centre of which has been placed a 
fragment of emplastrum lyttse, not larger than the head of a small 
pin. When the blister is formed, the lymph is to be deposited on the 
exposed surface of the derma. Mr. Crosse found this proceeding 
very successful in the case of a strong child, who resisted the opera- 
tion in the usual way ; and it is worth bearing in mind in cases where 
the ordinary operation has more than once failed. Another, and 
rarely practised mode of vaccinating, is to make a small incision, and 
place within it a thread impregnated with the vaccine lymph. The 
punctures are made obliquely through the epidermis, in order that 
the papillary surface may be attained without the effusion of blood, 
or with the escape of as little as possible. The virus which is in this 
manner introduced into contact with the derma is dissolved in the 
fluids of the tissues, and imbibed into the system, its agency thereon 
being indicated by certain local and constitutional effects. 

The local signs indicating that the vaccination has taken effect are 
first apparent on the third or fourth day after the operation, at which 
period there is a slight degree of elevation and hardness of the skin 
(papular stage) at the seat of the puncture, and a trifling blush of red- 
ness immediately surrounding it. On the fifth and sixth clay, a small 
quantity of liquor sanguinis is effused beneath the epidermis, and a 
vesicle is formed, which is whitish and pearly in appearance, of a 
roundish or oval figure, and umbilicated at its centre. The vesicle 
goes on increasing in size until the eighth or ninth day, at which 
period it has become fully distended, and has attained its perfect de- 
velopment. On the ninth day it loses the umbilicated form, it becomes 
flattened on the surface, and sometimes more convex than at the cir- 
cumference, and is composed of numerous small cells, which are filled 
with a limpid and transparent lymph. 

On the eighth day (sometimes the ninth), the perfect vesicle is 
surrounded by an inflamed variola, of a vivid red color (the pearl upon 
the rose), which gradually increases in extent from a few lines to more 
than two inches in diameter. The skin included by this areola is in- 
flamed and tumefied, and is frequently the seat of eruption of a crop 
of small transparent vesicles. On the tenth day, the redness and heat 
have increased ; there is considerable itching in the part, the move- 
ments of the arm are somewhat painful, and the axillary glands are 
liable to become tender and swollen. It occasionally happens, that at 
this period an erythematous blush spreads from the arm, over the 
surface of the body, in irregular patches. 

On the eleventh day the areola begins to diminish, the fluid con- 
tained within the vesicle has become purulent, and desiccation 

1 Lancet, vol. ii., 1850, p. 642. 



ERUPTIVE FEVERS. 495 

commences at its centre and proceeds gradually towards the circum- 
ference. During the succeeding days, the areola disappears more 
and more, the tumefaction subsides, and the vesicle desiccates into a 
dark brownish crust, of an irregular form. The crust, by a con- 
tinuance of desiccation, diminishes in size, and assumes a blackish 
hue. It is detached at the end of seventeen days after vaccination, 
and leaves upon the skin a depressed cicatrix, at the bottom of which 
are seen numerous small pits (foveolas), which correspond with the 
separate cells of which the vesicle was composed. The cicatrix is 
permanent, enduring for the remainder of life. 

To recapitulate: the two or three first days are those of incubation; 
the fourth is papular ; the fifth, sixth, seventh, and eighth, vesicular ; 
the vesicle presenting an umbilicated form, and attaining perfection on 
the last of these days ; the eighth day, moreover, is the period of the 
first phasis of areola, when the vesicle represents the "true pearl 
upon the rose;" the ninth, tenth, and eleventh days are pustular, the 
lymph becomes purulent, the umbilicated form is lost, the areola en- 
larges, and constitutional fever is established; the twelfth, thirteenth, 
and fourteenth days are those of desiccation ; the fifteenth, sixteenth, 
and seventeenth, of separation ; and these latter are succeeded by the 
fall of the scab. 

Such is the course of the vesicle of vaccinia, which is considered 
necessary to the protection of the system. When its progress is ir- 
regular, and its development not perfectly effected, the constitution 
remains in the same state in relation to the occurrence of variolous 
contagion as before the operation. It must be borne in mind, how- 
ever, that the local affection is never so well marked in the adult as in 
the child, although the extension of inflammation to the neighboring 
glands and the constitutional fever are often greater. 

The proper time for the performance of vaccination is infancy, be- 
tween the third and the seventh month. At an earlier or a later period, 
the diseases incidental to childhood may interfere with the progress 
of the case. Jenner pointed out the fact that certain diseases of the 
skin, particularly those of a vesicular kind, interfere with the proper 
development of the vesicle, and other influences are derived from age 
or idiosyncrasy. 

The constitutional symptoms accompanying vaccination are always 
Blight, and often scarcely perceptible. In some instances, however, 
a little fever is observed at about the eighth and three following days, 
this febrile reaction corresponding with the progress of inflammation 
of the areola. 

"secondary eruptions of vaccinia. 

Syn. Vaccinella. 

The general effects of vaccination occasionally offer some pecu- 
liarities. Thus, it sometimes happens, that, during the course of the 
vaccine pock, an eruption of vesicles appears upon the skin. Such 
an eruption lately fell under my observation in which vesicles and 



496 DISEASES FROM UNKNOWN ANIMAL POISONS. 

bullae 1 were developed upon inflamed patches on the greater part of 
the surface of the body. The principal features of this case were the 
following : 

Green, a child eighteen months old, was vaccinated at the London 
Small-pox Hospital, on Monday, June 7th, 1841. On the ninth or 
tenth day after the operation an eruption of red spots was perceived 
upon the forehead, which quickly extended to the face, neck, trunk, 
and arms, and by the thirteenth day was dispersed over the whole of 
these regions, the redness being augmented towards evening and 
during the night. On the sixteenth day I first saw the patient; the 
vaccine crust and areola were natural, the eruption had subsided on 
the face, and was now principally confined to the arms, chest, and 
back, the legs being nearly free. In these situations it existed in its 
successive stages ; there were small red spots, the earliest form of the 
affection, and larger patches, of a roundish or irregular form, of about 
the size of a fourpenny piece, several of these latter patches being con- 
gregated here and there, so as to form clusters of considerable size. 
The margins of the patches were of a dull red color, and somewhat 
elevated, while the centres presented a yellowish tinge, and in some 
situations were covered with numerous small vesicles, containing a 
limpid and transparent serum. On the eighteenth day, the redness of 
the patches was declining, their raised border had become lighter in 
tint than the centre, and the epidermis was desquamating over their 
surface, particularly on those patches where vesicles had existed. 
On the face the vesicles terminated in thin, brownish, and spongy 
laminae. I inoculated a healthy child with lymph taken from these 
vesicles, but without any result. 

In the early part of the present year I had an opportunity, through 
the courtesy of Dr. John Hall Davis, of seeing an infant in whom the 
secondary eruption of vaccinia was so severe as to be the cause of death. 
The eruption commenced upon the head and face, and thence extend- 
ed to the neck and chest. On the latter there were more than one 
hundred vesicles, presenting the characteristic flattened and umbili- 
cated form of the vaccine pock. They w T ere for the most part discrete, 
but every here and there were confluent clusters of three, four, and 
five. On the neck the vesicles were confluent, the slight and irregular 
intervals of skin between the large patches were vividly red, and the 
whole surface poured out an abundant ichorous discharge. The child 
had evinced a tendency to eczematous eruptions from its birth ; a 
circumstance deserving the attention of the medical practitioner. 

The following case occurs in the Archives de Medecine for Septem- 
ber, 1841. An infant a week old was vaccinated July 3d ; on the 
10th several papulae appeared on various parts of the body. On the 
15th there were eleven umbilicated vesicles on the abdomen and legs 
similar to those of vaccinia. Three children inoculated with lymph 
from this eruption had vesicles developed identical with those of ordi- 
nary vaccinia. 

1 Mr. Ceeley regards this eruption of a pemphigoid character as "strictly a vaccine 
eruption ;" he has seen it frequently on children, and occasionally on the cow and 
dog. 



ERUPTIVE FEVERS. 497 

Dr. George Gregory lately communicated to the Royal Medical and 
Chirurgical Society the case of a child in whom petechise appeared 
upon the skin four days after vaccination. The child was to all ap- 
pearance in perfect health. The areola was occupied on the eighth 
day by an extensive ecchymosis, and the body was covered with 
petechial spots. By the sixteenth clay, the petechige had commenced 
to fade. Five children of the same family were vaccinated at the 
same time, and with the same lymph, and went regularly through the 
disease. Dr. Gregory regarded this case as one of petechial cow-pox, 
in which the influence of the vaccine virus in the production of an 
hemorrhagic state of the system was demonstrated. Petechial cow- 
pox is rare ; Dr. Gregory had never before seen a similar case, and 
had only heard of two of the same kind. 

PROTECTIVE POWER OP VACCINATION. 

I now come to a question of the utmost importance, namely, the 
eflicacy of vaccination as a protection against small-pox. But before 
I engage in this discussion, it may be necessary to define precisely 
the meaning which I attach to the term vaccination. Vaccination I 
conceive to mean — 

1. That the lymph employed in the operation is pure. 

2. That it has been obtained from a vesicle which has passed regu- 
larly through the course described in the preceding section. 

3. That it has been procured from the vaccine vesicle, between the 
sixth and eighth day of its course. 

4. That the vesicle produced by this lymph in the vaccinated sub- 
ject shall have passed regularly through the stages known as the 
natural course of the vaccine pock, . and described in the preceding 
section (page 494). 

5. That at least one of the vesicles produced by vaccination shall 
have been permitted to remain unbroken and uninjured, until the 
natural vaccine crust shall have been formed, and shall have fallen 
in the natural course. 

6. That the cicatrix shall be well marked, and permanent, perhaps, 
also, foveolatcd. 

When the whole of these conditions are complete, vaccination is 
perfect and the person so vaccinated may be regarded as protected 
against small-pox. But if any of these conditions be incomplete, it 
would be monstrous to expect that the full influence of the vaccine 
protection could be exerted. Again, it has been observed, that the 
nearer the approach of the conditions to the standard above estab- 
lished, the more protective will be the influence effected by the 
operation, and vice versa 4 . 

The purity of the vaccine lymph is a point of the first consequence. 
The genuine lymph appears to undergo no change or loss of power 
by indefinite transmission, provided always that due attention has 
been directed to the fact of its being always obtained at the requisite 
period, and from a vesicle which has passed regularly through 
its course, in fact, from the true "pearl upon the rose." But 

32 



498 DISEASES FROM UNKNOWN ANIMAL POISONS. 

as the attention necessary for the assurance of this condition has, 
unfortunately, in many cases, been omitted, much spurious lymph 
has been mingled with that derived from the original source, and as a 
consequence, small-pox after vaccination has become more frequent, 
and vaccination has fallen into disrepute. It would, however, be 
unjust and unphilosophical, to attribute this apparent falling off in the 
influence of the vaccine lymph to any but its true cause, the one just 
mentioned. 

On this topic I was much gratified by a recent conversation with 
Mr. Marson, the resident surgeon and vaccinator of the London 
Small-pox Hospital. He informed me that when, in 1835, he became 
attached to the hospital, he found in use a lymph which had been 
employed there for nearly forty years, and which had become greatly 
enfeebled in its powers. Two years afterwards, namely, in March, 
1837, he fortunately met by accident with some new lymph of a very 
superior kind to his own, and possessing more active properties. 
That lymph he has continued to use until the present time (1856), and 
without injury to its powers, although during the intervening period 
he has vaccinated nearly 50,000 children, and distributed lymph to 
nearly 25,000 medical men. 

The period best suited for obtaining the vaccine lymph is the 
seventh day of the vesicle, which corresponds with the eighth day of 
the operation ; Jenner says between the fifth and eighth day, which is 
too indefinite. 1 If the vesicle appear incomplete on the seventh day, 
the removal of lymph might be deferred for a day, but it is important 
to obtain it before the inflamed areola is formed. After the areola is 
established, the lymph becomes altered in its character, and purulent, 
and either loses the power of exciting a pock, or produces one which 
is irregular in its appearance or course, and is incapable of conferring 
safety on the person vaccinated. It is true, that occasionally the 
fallen crust is sufficiently impregnated with the desiccated lymph to 
possess the power of exciting the disease, and is sometimes used as a 
convenient means of transporting the virus to warm climates ; but the 
crusts for this purpose must be selected with care, and even then are 
liable to failure. 

That the vaccine pock shall pass regularly through its course is 
the most important of all the conditions requisite for the success of 
vaccination. Jenner especially pointed out the necessity of this rule, 
for he perceived that its neglect might lead to the most serious 
results. That neglect has, I fear, very extensively existed, and many 
of the distressing consequences under which we now suffer are 
referable to it. The fulfilment of this condition is in itself the best 
assurance of the purity of the lymph, of the disposition of the 
system to receive its influence, and of the completion of the sub- 
sequent conditions. 2 

' Mr. Marson requires the vaccinated children to be brought back to him on the 
day-week of their vaccination ; consequently on the completion of the seventh day 
and dawn of the eighth; the lymph is therefore seventh-day lymph. On this day 
he generally finds the lymph fit for removal. 

2 It may not be out of plaee here to remind the vaccinator of the importance of 



ERUPTIVE FEVERS. 499 

When the vesicle passes regularly through its stages, the cicatrix 
which it leaves behind is strikingly characteristic, and may be 
depended upon as a proof of successful vaccination. But the absence 
of the foveolated appearance of the cicatrix is no proof that the pre- 
servative influence of vaccination has not been established, provided 
that a permanent cicatrix of the ordinary size be present. But when 
there is difficulty in discovering the cicatrix, or the latter is small, it 
may be unhesitatingly concluded that the pock did not complete its 
necessary stages, and, consequently, that the person is still unpro- 
tected. 

VACCINATION TESTS. 

With the view to ascertain whether vaccination has been effective, 
several plans have been adopted which are termed tests. The most 
efficient of these is inoculating with small-pox after vaccination ; 
revaccination is a second test ; and a third is that described by Dr. 
Bryce, of Edinburgh. Bryce's test consists in revaccinating a few 
days after the first vaccination. In this case, if the constitution be 
already affected by the vaccine influence, the second pock hurries 
through its stages, and speedily reaches an equal development with 
the first, arriving at its acme at the same time, and desiccating and 
forming its crust contemporaneously with its predecessor. 

RE-ESTABLISHMENT OF THE PROTECTIVE INFLUENCE OF VACCINIA. 

For several years past opinion has been divided relative to the 
protective influence of vaccination against small-pox. By some it is 
believed that the power of vaccination as a defence against variola 
diminishes gradually with the advance of age ; and by others, it is 
thought that the vaccine virus introduced by Jenner has degenerated 
during the sixty-six years that it has been transmitted through the 
human race, and lost a portion of its protective quality. I shall not 
Stop to inquire into the merits of these two questions, both warmly 
contested and supported by powerful advocates, but at once proceed 
to examine the propositions that have been made and acted upon for 
the purpose of supplying a remedy against the evil consequences 
which they would imply. As a means of perpetuating the vaccine 
influence, two modes of procedure have been recommended, namely, 
revaccination, and variolation after vaccination. And with the view 
to meet the second evil, three plans have been adopted, namely, retro- 
vaccination, variolo-vaccination, and recurrence to the primary lymph 
from the cow. 

being very particular with regard to the purity of the instrument used in performing the 
operation, ami indeed of tin- necessity for nicety and care throughout the entire process. I 
was lately called upon to give my opinion in the Coroner's Court, upon a case of death 
which had resulted from vaccination. Another child, vaccinated at the same time, had 
oai rowly escaped the effects of inflammation of the absorbents and suppuration of glands ; 
and there was every reason to fear that these dreadful eonsen.iiences resulted from an im- 
pure lancet. 



500 DISEASES FROM UNKNOWN ANIMAL POISONS. 



REVACCINATION. 

The phenomena of contagion, as it affects the human frame, develop 
two important facts : firstly, that the workings of contagion in the 
animal organism destroy the susceptibility of that organism to take 
on a similar action ; secondly, that from the moment of completion of 
the workings of contagion, the organism becomes gradually and 
slowly restored to the condition which it possessed previously to the 
development of contagion. In the abstract, these propositions are 
incontrovertible, but they require the modification implied in the 
estimate of time, to render them applicable to the thousand peculiar- 
ities that occur in daily practice. Thus, in relation to the first, we 
have to inquire, For what length of time the susceptibility is de- 
stroyed ? and in relation to the second, At what period after contagion 
is the restoration of the organism so far effected, that a second attack 
of contagious disease may take place ? To both these questions the 
answer is, We know not. All that we can venture to affirm with 
regard to them is, that, in one person, a single attack of contagious 
disease appears to be protective of the individual for life ; while, in 
another person, a second attack may occur in a short period, the 
precise limits of that period not being correctly established. The 
determination of the shortest period at which contagious disease may 
resume its influence over the system is a point of much importance, 
and one of legitimate investigation. It is in the field of numerical 
medicine alone that we must look for a solution of the questions which 
are now proposed. 

The reasoning, which is here directed to contagion in general, 
applies with particular force to the protective influence of the conta- 
gion of small-pox. A single attack of small-pox would appear, in the 
majority of cases, to protect the individual for the rest of life, but in a 
smaller number of instances, the variolous constitution is still active, 
and a second, a third, and even more attacks may be experienced. 
Now, that which is true with regard to variola, is equally true with 
regard to vaccinia ; for variola and vaccinia are, in their essential 
nature, one and the same disease. 1 Again, it, is admitted at all hands, 
that severity in the manifestation of the variolous disease affords no 
security to the system greater than that to be derived from the mildest 
form ; and as vaccinia is variola in the mildest shape in which it can 
be presented to the human organism, the question of revaccination 
resolves itself into the propositions stated above. 

If we admit that vaccination, although perfectly protective of the 
constitution against the recurrence of the small-pox contagion for an 
unknown, and probably variable space of time, ultimately loses its 
powers ; and if, in the next place, we inquire what means present 
themselves of perpetuating its protective influence, the most natural 
and rational method that suggests itself to our mind is revaccination. 

1 It is proper to mention, in this place, that many opinions are opposed to this belief. 
Dr. Robert Williams observes, "Vaccinia is a disease sui generis," and further on he 
remark.-, "It is likewise by no means proved, that the small-pox and the cow-pox are 
identically diseases of the same species." — Vol. ii., p. 49. Elements of Medicine. 



ERUPTIVE FEVERS. 501 

Revaccination, or a repetition of vaccination, is a simple and harmless 
operation, producing a mild and trifling indisposition when the system 
is unprotected, but no effect whatsoever when the organism is safe. 
Here, then, we find the operation to be acting as a test of the safety 
of the individual, and no objection can possibly be raised against its 
use. If the organism be safe, it produces no effects ; if the organism 
be unsafe, it produces a trifling inconvenience, but it leaves a bulwark 
of safety in its train. 

The only question that remains to be considered in relation to re- 
vaccination, bears reference to the periods at which the operation 
should be performed. This is a matter of trivial importance in com- 
parison with the principle which it involves. I would say, let vac- 
cination be performed every five years, or every seven years, or every 
ten years. But, as our object is protection, let us not defer that pro- 
tection too long. If the operation succeed at the end of five years, 
that fact affords the strongest proof that the repetition is not too fre- 
quent. If it fail at the end of five years, let- it be practised at seven ; 
if it fail at seven, make a third attempt at ten ; if the operation fail 
then, it may be adopted at successive intervals, but the person inocu- 
lated has the satisfaction of knowing himself safe, at a most insignifi- 
cant inconvenience. 

Numerous cases have been adduced in which an attack of small-pox 
has followed vaccination. 1 I care not to inquire if vaccination have 

1 It must not be imagined that Jenner ever contemplated an infallible remedy in 
vaccination ; he merely expressed his belief that vaccination would be found to pro- 
tect the organism in an equal, if not in a greater degree, than variola, and with a pro- 
digious saving of suffering and danger. In respect of this expectation, Dr. Robert 
Williams remarks, that it " has not altogether been verified; the evidence at present 
accumulated showing the attack of the latter (secondary small-pox) to be only in the 
ratio of a half to one per cent., while the attacks of the former (small-pox after vac- 
cination) are not less than five per cent, or from five to ten times greater. It is enough 
of glory, however, to the discoverer of vaccination, and of honest pride to the profes- 
sion who have adopted it, to be able to state, that by the discontinuance of the prac- 
tice of inoculation, the total number of persons attacked by natural smallpox in this 
country, taking the most unfavorable calculation, is reduced one-half, or probably 
from 20i). Duo annually, to about 130,000 annually, while the number of deaths have 
been reduced in a still greater ratio, or from 60,000 to about 11,000; also, that the 
accidents incident to the disease, as blindness, deafness, lameness, and the endless 
catalogue of miseries that follow it, are also reduced almost to nothing. This result 
is that of England and Wales generally, and it is still capable of being very greatly 
reduced, for among the better protected class of persons, as the army, only one soldier 
has been attacked by small pox in every two thousand, annually; so that taking the 
army at 100,000 men, the mortality is only four from small-pox in the whole of that 
i roe annually. The navy appears also to experience a similar immunity, for 
"ui of ■ > mean strength of 79r>8 seamen, seven only died, in seven years, of small-pox 
in the Mediterranean and Peninsular commands, while, in the West Indian and North 
and South American commands, none whatever. On the Continent, also, where the 
governments are awakened to the great truth that the health and industry of the 
lower orders furin tl I basis of national wealth and greatness, and where vac- 

cination is consequently made of national importance in the matter of legislation, we 
find thai the mortality from Bmall-pox, though greater than in our army, is infinitely 
less than In England and Wales generally. In Prussia, for example, according to the 
table given by Hoffman, <>n an average of a million of deaths, only 8191 were caused 
by small-pox, or one in 122. In England and Wales, however, out of Ul,t>07 deaths, 
981] were occasioned by small-pox, or one in 25, nearly ; thus showing that the" country 
which gave birth to \ accraation, suffers six times more by small-pox than that of its 
wiser and more considerate neighbor." — (P. 49.) 



502 DISEASES FROM UNKNOWN ANIMAL POISONS. 

been perfect in those cases, for instances are equally numerous in 
which small-pox has followed inoculation, and small-pox itself, both 
discrete and confluent. These facts prove nothing unfavorable to the 
claims of vaccination as a protective agent against small-pox ; they 
prove only that which daily experience tends constantly to corrobo- 
rate, namely, that man has still much to learn. There can be no 
question that instances of variolous constitution exist in which all 
preventive means that we can suggest would be utterly futile, but 
these are, happily, exceptional cases. We are, I fear, completely 
ignorant of the laws which govern contagious disorders. It has been 
observed that rubeola and scarlatina, like variola, occur but once in 
the lifetime; persons having once suffered from these diseases consider 
themselves secure from infection, and yet how frequently we have 
occasion to see the rule nullified, and secondary attacks developed. 
The following table, quoted from Dr. Heim, in the Report of the Vac- 
cination Section of the Provincial Medical Association, is exceedingly 
interesting, as showing the relative frequency of success in vaccinating 
after small-pox and after vaccination : 

Vaccinated after small-pox with success, . . .32 

'• " . modified, . . . .26 

" " without effect, . . .42 

— 100 
Revaccinated with success, ...... 34 

•' " modified, . . . .25 

'• " without effect, . % .41 

— 100 

Revaccination is at present being performed very extensively on 
the Continent, which would seem to imply distrust in the powers of 
the primary vaccination. The results of these operations, however, 
are calculated to increase our knowledge upon this important subject. 

The following are the conclusions of the Commission of Vaccine, 
on vaccination performed in France, during the year 1839 : 

1. That the simultaneous vaccination of the mass instantly arrests 
the progress of the variolous epidemic. 

2. That if vaccinia be not an absolute and infallible preservative 
against variola, it is at least the most certain, and the most exempt 
from danger. 

3. That varioloid, in the majority of cases, is the only inconvenience 
to which the vaccinated are exposed. 

4. That there seems no reason for the belief that the long vaccinated 
are not as surely preserved at the present day as they have hitherto 
been ; nor that the recently vaccinated have received less security 
than those who preceded them. 

5. That the complete success of revaccination affords no proof that 
the individual had ceased to be protected by vaccination, and that he 
had again become susceptible of variola. 

6. That a second vaccination does not appear to possess the power, 
any more than the first, of protecting all persons indiscriminately from 
the risk of a future attack of variola. 

7. The Government ought not to command a general revaccination. 



ERUPTIVE FEVERS. 503 

8. That the total extinction of variola is to be effected by the uni- 
versal adoption of vaccination. 

VARIOLATION AFTER VACCINATION. 

Inoculation after vaccination has been proposed as an additional 
security against the contagion of small-pox. To those who regard vac- 
cinia and variola as different diseases, such a suggestion is likely to be 
received with approbation ; but if we view these disorders in their true 
light, namely, as one and the same affection, inoculation after vaccina- 
tion is but a repetition of revaccination, and is, consequently, inca- 
pable of bestowing any superior advantage. 

RETRO- VACCINATION. 

This operation is attended with some difficulty, in consequence of 
the indisposition evinced by the assimilative powers of one group of 
animals to the reception of virus derived from a different order. The 
operation has, however, succeeded several times in the hands of Mr. 
Ceeley, and its results are conclusive. This gentleman observed a 
slight increase in the frequency of the pulse of the animal as soon as 
the inoculation had taken effect, and the local affection was attended 
with a moderate degree of inflammation. The vesicles were produced 
late, and good lymph was procured on the tenth day. 

When children were vaccinated with this retro-vaccine lymph, the 
development of the pock was found to be retarded, the papular stage 
was not established until the sixth or seventh day, the areola was com- 
plete on the tenth or twelfth day, and declined during the two follow- 
ing days. The vesicles, in some instances, were smaller or less firm 
than usual. With these exceptions, no difference could be detected 
between the retro-vaccine and the ordinary current lymph, and these 
differences were entirely lost after three removes in the human subject. 
From these experiments, I think it may justly be inferred, that for the 
purpose of improving the vaccine lymph, retro-vaccination, or passing 
it again through the cow, is useless. 

VARIOLO-VACCINATION. 

Inoculation with the variolo-vaccine lymph is attended with the 
same difficulties of transmission as are common in the case of unas- 
aimilated virus. Out of twenty punctures inoculated with lymph 
derived from the variolo-vaccine vesicle, Mr. Ceeley obtained only six 
vt'siclf.-. These, when they appeared, were characterized by their 
early Inflammation, and by tardiness and irregularity in progress and 
development. The secondary fever, which arose and subsided with 
the areola, was severe, and if the vesicle were ruptured, ulceration 
and sloughing were liable to ensue. The effects of this lymph are 
illustrated in the following successful case: "Emma Jacock, aged 
fourteen, dark, swarthy complexion, thin skin, rather florid; two 
points of sixth-day Lymph, and four of eighth-day lymph, were inserted 
into six punctures; on the fifth day, four of the papulie had ash- 



504 DISEASES FROM UNKNOWN ANIMAL POISONS. 

colored summits, and seemed vesicular, two were doubtful. On the 
seventh day, there were five small, distinct, reddish-gray, or ash- 
colored vesicles, one very small. On the eighth day, the vesicles were 
advancing, of unequal size, and of irregular form. Here I was forcibly 
struck with the strong resemblance some of these vesicles bore to those 
of the eighth day, depicted in Jenner's work, on the arm of Hannah 
Excell, which he thought so remarkably like the results of small-pox 
inoculation. My patient stated that she felt slightly indisposed on 
the fifth and sixth days, that the axilla was painful on the seventh 
day, and that she was then giddy and sick, but felt worse on this the 
eighth day. On the ninth day the areola commenced, and she com- 
plained only of headache. On the eleventh day it was fully deve- 
loped, when all her symptoms returned in an aggravated form. On 
the twelfth day it declined ; but the turgid vesicles having burst the 
flimsy cuticle, renewed inflammation and induration, with circum- 
scribed sloughing and ulceration of the skin, ensued, and rather deep 
scars are now visible." 

After narrating the results of several successive removes of the 
variolo-vaccine lymph, Mr. Ceeley remarks, " Nothing could be more 
satisfactory or gratifying than the progress now made, which it would 
be needless further to detail ; I shall therefore abstain from the de- 
scription of individual cases, after adducing one example from the 
fourteenth remove, as a type of what might be produced in similar 
subjects, namely, an infant fourteen months old, florid, plump, and 
healthy, with a fine, clear, thick, smooth skin. 

" In the majority of instances, in propagating from arm to arm, dis- 
tinct papulation was apparent on the second day ; on the third it was 
not only visible but elevated and well-defined ; on the fifth and sixth, 
vesiculation was abundantly obvious, and lymph was often taken on 
those days. On the seventh day vaccination was frequently per- 
formed, and points were often charged; on the eighth the vesicle com- 
monly exhibited a bold, firm, and glistening aspect ; between this pe- 
riod and the ninth day the areola generally commenced (but in young 
infants with tense and sanguine skins, it appeared early on the eighth); 
by the tenth day the vesicle was commonly in its greatest beauty and 
highest brilliancy, glistening with the lustre of silver or pearl, having 
the translucency and appearance of crystal, or shining with a pale 
blue tint, occasionally of a dull white or cream color, bold and ele- 
vated, with a narrow centre and a broad margin, or flat and' broad in 
the centre, with an acute margin, occasionally not raised above the 
level of the skin ; on this and the eleventh day an extended and gene- 
rally vivid areola existed, with more or less tension and induration 
of the integuments. At this time the lymph was frequently pellucid, 
and often perfectly efficient. From the eleventh to the thirteenth day 
gradually increasing in many individuals, both children and adults, 
sometimes the entire vesicle, at other times only the central parts, 
reflected a blue or slate-colored lymph, from the congested or ecchy- 
mosed subjacent adventitious structures, proportioned to the texture 
and degree of translucency yielded by its desiccating epidermis. On 
the thirteenth and fourteenth day, particularly on clear skins mode- 



ERUPTIVE FEVERS. 505 

rately thick, the vesicles attained a considerable size, measuring often 
in their longest diameter six and a half or seven lines, and acquired 
a light brown centre, from commencing desiccation, which was sur- 
rounded with an outer margin of dull white, or pale dirty yellow, soft 
and flaccid, and still possessing fluid contents. During this period 
the areola, of a dull red or damask hue, would revive, and decline 
again and again, and even to the sixteenth or eighteenth day, the 
period to which complete desiccation was frequently protracted. The 
crust commonly partook of the form of the vesicle ; it was often pro- 
minent and bold, varying in color from that of a chestnut to that of a 
tamarind stone. It fell generally about the twenty-third or twenty- 
fifth clay, often later." 

" The cicatrices were of variable depth and extent. When the 
vesicles remained unbroken on a thick sanguine skin, they were deep, 
but on a thin skin, shallow ; they were not always proportioned in 
width to that of the vesicle, the smallest cicatrix often succeeding the 
largest vesicle, but the later the crust fell, of course the deeper the 
cicatrix, which, on these occasions, was often beautifully striated. I 
need scarcely say, that where the vesicles were accidentally broken, or 
spontaneously burst, much mischief ensued, deep sloughing of the 
skin, &c. Spontaneous bursting did not often occur, except in those 
subjects possessing the before-mentioned and well-known obnoxious 
constitutional enderrnic characteristics, upon whom we must always use 
active lymph with some risk. 

" When the lymph in the first remove produced normal vesicles, 
and as soon as it had passed readily from arm to arm, the constitu- 
tional symptoms, though mild, were most commonly well marked. 
In infants, restlessness, fretfulness, and inappetency about the fifth or 
sixth day were very common, sometimes as late as the seventh day. 
Very few escaped feverish symptoms on the ninth and tenth days, 
many had vomiting and diarrhoea. From childhood up to puberty 
the primary symptoms from the fifth to the seventh day were unequivo- 
cally visible, and often complained of; fever, vomiting, delirium, and 
diarrhoea were not unfrequently witnessed at the commencement, or 
during the progress of the secondary symptoms. In adults, of course, 
more complaint was made, headache, chilliness, anorexia, and some- 
times thirst, on the fifth or sixth day ; increased on the seventh day, 
with axillary tenderness ; but on the ninth and tenth days much gene- 
ral febrile complaint, disinclination, and even inability, to leave the 
bed. But in several instances, amongst young children, little or no 
complaint was made or indicated; all the members of the same family, 
vaccinated from the same source, might be differently affected. One, 
for instance 9 would not cease from pastime, occupation, or meals, while 
another, particularly if older, would be indisposed several days. 
Neither die Dumber nor the magnitude of the vesicles seemed to 
determine the amount of the primary disturbance. If properly deve- 
loped, small vesicles often gave rise to marked constitutional symp- 
toms, ami the most splendid vesicles were often seen with trivial, some- 
times scarcely appreciable disturbance." 

" The secondary symptoms are often as active with three or four, 



506 DISEASES FROM UNKNOWN ANIMAL POISONS. 

as with six or eight vesicles ; acceleration of the pulse was frequently 
noticed, when no other symptoms appeared. Both primary and 
secondary symptoms very commonly showed a remitting type." 

With respect to cutaneous eruptions, Mr. Ceeley observed but one 
in the adult, and in children nothing approaching the varioloid 
character. "Roseola, strophulus, lichen, were the principal erup- 
tions." 

Dr. Basile Thiele, 1 of Kasan, has succeeded several times in inocu- 
lating the udder of cows. When children were inoculated with 
matter taken from these pocks, the effects produced were more intense 
than those occasioned by the ordinary vaccine lymph. In some 
cases, Dr. Thiele observed two febrile attacks, one between the third 
and fourth day, the other between the eleventh and fourteenth, and 
these severe consequences were not lost until the sixth remove. In 
one case, he produced true variola, and inoculation with the matter 
of these pocks gave him vaccinia. 

RECURRENCE TO THE PRIMARY VACCINE VESICLE. 

Lymph has been procured directly from the cow in several counties 
of England, and numerous children have been inoculated with this 
primary lymph ; indeed, the removes from these sources have now 
come into almost general use. The gentlemen to whom we are 
principally indebted for this supply are, Mr. Estlin, of Gloucester- 
shire ; Mr. Fox and Mr. Sweeting, of Dorsetshire ; and Mr. Ceeley, 
of Buckinghamshire. It has also been obtained and employed in 
France, by M. Saunoy. 

"Whenever an attempt is made to inoculate man with the virus 
derived directly from the cow, or, on the other hand, to inoculate the 
cow with humanized vaccine lymph, or with small-pox, great diffi- 
culty is encountered. There would seem to exist an indisposition to 
the assimilation of virus derived from an animal of a different order, 
but when this lymph has once become assimilated, all difficulty is at 
an end. When inoculation is effected, a remarkable difference is 
perceived in the consequences of the two kinds of lymph ; thus, in 
the transference of the tymph of small-pox to the cow, the virus is 
greatly modified, and the resulting pock is chastened and mild ; while, 
on the contrary, the lymph of the variola vaccinae first introduced 
into the tissues of man, gives rise to symptoms of greater severity 
than those produced by humanized lymph. How far this difference 
of effect may be dependent upon the different quality of the fluids of 
an herbivorous and a carnivorous (the human infant) or semi-carni- 
vorous animal, I am unprepared to say. I think it not improbable 
that the cause might be found in this difference of character. 

The effects of vaccination with primary lymph are, according to 
Mr. Ceeley, as follows : On the second day after vaccination there is 
an unusual degree of redness around the puncture ; the redness 
declines on the two following days, and becomes concentrated in the 
point where the papula arises. The elevation of the papula com- 

1 Bulletin de rAcademie Roy. de Med., Jan., 1841. 



ERUPTIVE FEVERS. 507 

mences on any one of the days between the sixth and the tenth. 
Desiccation of the vesicle is also protracted ; it contains fluid until 
the sixteenth or eighteenth day, and the crust remains adherent until 
the end of the fourth or fifth week. The areola is completed from 
the eleventh to the sixteenth day, and is sometimes covered with 
small supernumerary vesicles, and accompanied by a general erup- 
tion of papulae, vesicles, or bullae. When the vesicle is ruptured in 
unfavorable constitutions, irritable sloughing sores are sometimes 
formed, and the fall of the crust is occasionally succeeded by a yellow, 
foul excoriation. 

The vesicles produced by primary lymph are very variable in 
appearance, sometimes they are " remarkably large, and finely deve- 
loped," at other times they are smaller, and " less developed than other 
vesicles;" but they " admit of a very remarkable improvement, by 
transmission of the lymph through a series of well-selected subjects. 
By this process, also, in a very short time, most of the defects and 
some of the evils connected with the use of primary lymph may be 
dissipated, and the lymph rendered milder, and more suited to gene- 
ral purposes." " Children are the best, certainly, for the purpose, 
and such should be selected as possess a thick, smooth, clear skin, and 
have a dark complexion, and are not too florid, but still, plump, 
active, and healthy." "By a steady and judicious selection of these, 
and similar subjects, in a few (even three or four) removes, the severity 
of the local mischief becomes manifestly materially diminished, the 
vesicles acquire a magnitude and beauty, often greatly superior to 
what is daily witnessed ; and in a short time the lymph may be trans- 
ferred with safety to others, even more sanguine and robust, where, 
it is well known, lymph, if good for anything, will produce the finest 
and most perfect vesicles." " As we advance, we find the necessity 
of preparing the most objectionable subjects, and the advantage of 
subjecting many of them to the same preliminary treatment, which the 
best and most expert inoculators of small-pox formerly so successfully 
adopted for their patients ; for it is a long time before some individuals 
can be safely vaccinated with this active lymph, even though taken 
from the mildest vesicle." 

Recurrence to the primary lymph from the cow appears to me to be 
the only unobjectionable method of improving the current lymph, and 
correcting the deterioration which has arisen from neglect of the pre- 
cepts of Jenner. Lymph from this source must necessarily be pure, 
and its use should therefore be encouraged. 1 

Treatment. — Any morbid conditions arising accidentally from 

1 Dr. Lichtpnstein, in a paper entitled, "On tlie sources from which matter preservative 
againsl the Bmall-pox has been derived," in Hufeland's Journal for 1841, remarks, that 
limpid lymph taken from the pustules produced by tartarized antimony, and inoculated in 
a jMTr-on who has not been vaccinated, produces vesicles, which cannot be distinguished 
from those of vaccinia. These vesicles appear to be equally protective against small-pox 
with the cow-pox, and the matter may be transmitted from person to person in the same 
manner. The auihor of the paper has inoculated and reinoeulated thirty-one persons with 
the matter procured from this source; and these persons were protected during an epi- 
demic of small-pox, although placed in association with patients affected with that disease. 
Credat Juda'us, non ego! 



508 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

vaccination should be treated in accordance with the general princi- 
ples of therapeutics. Febrile symptoms may call for the employment 
of antiphlogistic remedies ; and the local dermatitis, when it assumes 
a form of unusual severity, may be subdued by means of a compress 
of linen wetted in a spirituous lotion and covered with oiled silk, or 
by means of a piece of Alison's prepared lambskin saturated in water. 
If sloughing or ulceration occur, water-dressing should be continued 
until the inflammation, is removed, and slightly astringent washes or a 
mild ointment applied subsequently. 



CHAPTER XVI. 

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN. 
DISEASES OF THE VASCULAR STRUCTURE. 

The disorders of the vascular structure of the skin are two in num- 
ber, one affecting the cutaneous veins, and giving rise to enlargement 
of those vessels ; the other affecting the capillary and arterial system, 
and producing tumors of various magnitude. These states are repre- 
sented by the following terms : 

Hypertrophia venarum. 

Ngevi vasculosi. 

Hypertrophy of the veins of the skin, of its papillary and deeper 
layers, is an accidental affection occurring in the adult, or more com- 
monly at an advanced period of life. Nsevus vasculosus is generally 
congenital ; but some of its minor forms, such as the ngevus araneus, 
may be developed at any subsequent age. 

HYPERTROPHIA VENARUM. 

Hypertrophy of the veins of the skin occurs in two situations : on 
certain parts of the face, where it is the result of a defective tone of 
the tissues, or torpid action of the functions of the skin ; or, on the 
limbs, particularly on the lower extremities, where it is commonly 
accompanied with a varicose state of the subcutaneous veins. 

In the face, enlarged venules are most frequently seen on the nose, 
on the cheeks, and upon the chin. On the nose they are accompanied 
with a coarse state of the skin, and sometimes with actual hypertrophy 
of that organ. Occasionally I have seen them so large, and their 
presence has so retarded the circulation of blood in the organ, as to 
give a livid and swollen appearance to the extremity of the nose. In 
their more usual state, they are met with on the sides of the nose, 
where two or three, and sometimes as many as six, large trunks may 
be seen collecting their tributaries from the border of the ala, and 



DISEASES OF THE VASCULAR STRUCTURE. 509 

from the extremity of the organ. The trunks vary in length, from 
half to three-quarters of an inch, and sink into the depths of the skin 
above the alar cartilage to reach the mucous membrane. On the 
sides of the bridge of the nose, the enlarged venules sometimes consti- 
tute a plexus, as they do also on the cheeks. This state of the veins 
of the skin is simply one of enlargement or hypertrophy, dependent 
on vascular determination or congestion, and a subsequent torpid 
function of the part, and is unconnected with disease of the skin, or a 
special morbid state of the system. In this respect it differs from the 
venous plexus which is met with in patches of the skin, the seat of 
syphilitic tubercles, and also from the enlarged state of the venules of 
the skin, which is found in association with the non-ulcerating or 
superficially-ulcerating tubercles of lupus. 

On the limbs, and particularly on the thighs, the enlarged venules 
are larger than those of the face, and more deeply imbedded in the 
skin, communicating, in fact, with the subcutaneous veins. They are 
sometimes straight, like the venules of the face, or disposed in a super- 
ficial plexus ; but more frequently they form patches, which are 
uneven on the surface from the projection of the coils of the distended 
veins, of a purplish or bluish color, the tint of blue being greatest 
where the veins come nearest to the surface, and of considerable 
thickness, but at the same time very little elevated above the level 
of the surrounding skin. They are, in fact, patches of varicose venules, 
and are usually associated with a varicose state of the subcutaneous 
and deeper veins. 

Treatment. — My practice in the treatment of enlarged venules of 
the nose and face is to touch the trunks with a fine point of potassa 
fusa, taking care to carry the point down to the vessels, so as to 
produce coagulation of the contained blood. This little operation 
requires care, in order to render as small as possible the pitted cicatrix 
which is apt to follow. When the hypertrophia venarum is spread 
more or less extensively over the face, it is necessary to improve the 
tone and nutritive functions of the skin by means of the stimulant 
and astringent action of the bichloride of mercury lotion, or by the 
more general stimulation of the compound hypochloride of sulphur 
or juniper tar ointment. 

For the varicose venules of the lower limbs, the only efficient treat- 
ment is, continued pressure, for which purpose the mercurial plaster 
spread on wash-leather, and a bandage, are best suited. These cases, 
however, from the nature of their cause, are less remediable than 
hypertrophous venules occasioned by altered nutrition and innerva- 
tion of the affected part. 

Even in this slight affection it is necessary to improve the vital 
functions, and depurate and invigorate the blood by constitutional 
means. Very few cases will be found in which elimination and restora- 
tion of potver are not needful. 



510 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 



N2EVI VASCULOSI. 

Syn. Teleangiectasia. Vascular ncevus. Erectile tumors. Arterial 
ncevi. Venous ncevi. Ncevus araneus. Ncevus flammeus. G-efass- 
muttermaler, Germ. Signes; Taches devin, Fran. Mother s marks. 

The vascular rete of the derma is liable to become dilated, and to 
give rise to the formation of red patches and slightly elevated tumors, 
called vascular ncevi. Vascular nsevi present considerable variety in 
relation to extent, tint of color, and tumefaction. Occasionally, the 
vascular dilatation is limited to a mere point, from which several 
enlarged venules pass off in different directions. This kind of nsevus 
rarely increases in size ; it is met with on the face and limbs, and 
from the peculiarity of its appearance has been named ncevus araneus. 
Proceeding upwards from this nsevus araneus, the diseased spots may 
be found to present every degree of size, and their dimensions are 
frequently so large that they have been seen to cover the whole of one 
side of the face, the ear, and part of the scalp. The tint of color of 
vascular naevi is dependent on two conditions, the extent of dilatation 
of the capillary rete, and the degree of excitation of the vascular 
system. Thus, if the capillaries be only moderately dilated, so as to 
offer little impediment to the circulation, and the latter be active, the 
blood will retain its arterial hue, and the color of the nsevus be brightly 
and vividly red. If, on the contrary, the vascular rete be dilated in a 
high degree, the blood will travel slowly through the tortuous tubes, 
and, assuming its venous character, the nrevus will present a purple, 
and even a livid hue. Intermediate degrees of dilatation or impediment 
to the circulation, will naturally produce different tints of red. Similar 
changes of color are apparent in the same nsevus, under different 
degrees of excitation of the vascular system. Thus, in a state of 
repose of the individual, the spot may be only moderately colored and 
livid, while, in a state of temporary excitement, the spot will assume 
a most intense and vivid red. The circumstances which affect the 
color, modify also the degree of tumefaction. In a state of repose it 
is ordinarily flaccid, and probably scarcely raised above the surface ; 
but in a state of excitement of the circulation, it will become tense 
and tumid. In relation to tumidity, as great variety is met with 
among nsevi as is found in their other characters. Some are not 
perceptibly raised above the level of the surrounding skin, while 
others form prominent tumors. 

Vascular nsevi, when of small size, give rise to little or no incon- 
venience; but when large, they are hot, painful, and throbbing. In 
the latter state they communicate a distinct pulsation to the finger, 
synchronous with that of the heart's beat. Vascular naevi are some- 
times stationary, but more frequently they increase slowly in size by 
the gradual extension of the morbid state of the capillary rete to the 
vessels of adjacent parts. Their growth is not always limited to the 
skin, for they are apt sometimes to extend more or less deeply into 
the subcutaneous tissues. Left to themselves, they will often continue 
the whole of life, without giving rise to any inconvenience; at other 



DISEASES OF THE VASCULAR STRUCTURE. 511 

times they may ulcerate and slough, or throw out a fungous growth, 
this change being accompanied by repeated hemorrhage, and termi- 
nating fatally. At all times the hemorrhage is troublesome, and even 
dangerous, when vascular ngevi are accidentally wounded. 

Dupuytren has the merit of first pointing out the analogy of struc- 
ture of vascular ngevi with the erectile tissue, and since the announce- 
ment of this similarity, they have been commonly termed, erectile tu- 
mors. These ngevi have been described from the earliest times as mo- 
ther's marks, and have been referred to the influence of moral emotion 
on the part of the mother during pregnancy. In pursuance of this 
explanation, we still hear them spoken of, in popular language, as 
bunches of red and black currants, strawberries, raspberries, blackber- 
ries, lobsters, &c, and it is supposed that the mother, in these cases, 
had a particular longing for the object represented. 

From the above description it will be seen that all vascular ngevi are 
identical in structure, and that differences, when they exist, are refera- 
ble to more or less dilatation of the vascular rete. Where the rete is 
dilated to a moderate extent, and the color of the ngevi is brightly red, 
we may call them, for the sake of distinction, arterial nosvi ; and 
where the capillary rete is very much dilated, and the color is blue or 
livid, we may call them venous na>vi. The term varicose ngevi has been 
sometimes applied to the latter ; but the use of this term is objectiona- 
ble, for two reasons : in the first place, it would seem to indicate a dif- 
ference of structure, which does not exist ; and, in the second place, 
the term is wanted for those bluish subcutaneous enlargements which 
consist of a plexus of small varicose veins, and are so frequently asso- 
ciated with varix of larger veins. 

As far as my observations have gone, and I have dissected many vas- 
cular ngevi, there is no addition to the normal number of capillary ves- 
sels in the affected part. They are enlarged in calibre, with corres- 
ponding hypertrophy of their coats, with enlargement of their meshes, 
with hypertrophy of the intervascular tissue, and dilatation of their 
appertaining arterial and venous trunks. 

Treatment. — When the nasvus is of large size, gives rise to little 
inconvenience, and advances but tardily in its growth, it had better be 
left alone, or simply treated with cold and styptic applications, with 
moderate pressure. When, however, these conditions are reversed, an 
attempt may be made to destroy it, bit by bit, by pencilling a small 
portion of its surface, from time to time, with nitric acid. In this 
way, in the course of time, a ngevus of large size may be cured. 

When the ngevus is small, it may be removed by excision, or if it 
be of moderate size, and danger be anticipated from division of the 
arteries which supply its base, it may be dislodged by the operation 
proposed by Mr. Liston, which combines with incision the use of 
Ligatures passed through its base, and firmly tied. This plan has the 
advantage over all others of getting rid of the morbid structure 
expeditiously, without the chance of hemorrhage. In certain cases, 
the ligature passed through the base of the ngevus may be used with- 
out the incision; if the ngevus be extensive or elongated, several 
ligatures may be required ; and in some situations it may be desirable 



512 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

to leave needles in the base of the tumor, and fasten the ligature be- 
neath them; where the tumor is pedunculated, a simple circular liga- 
ture may employed. 

The spider naevi, and those of very small size, may generally be 
cured by introducing into them a point of potassa fusa; while, in some 
instances, touching the exterior with the caustic will suffice for their 
destruction. 

Dr. Marshall Hall proposes the breaking up of the vascular struc- 
ture of naevus by means of a cataract needle with cutting edges, 
avoiding any external opening, save that through which the instrument 
has entered. Several instances are recorded in which the carotid ar- 
tery has been tied for naevi of large extent. 

In flat naevi, Dieffenbach recommends the use of a compress of lint 
to be firmly bandaged on the morbid structure, and frequently wetted 
with liquor plumbi diacetatis, or a solution of alum. The lint should 
be disturbed as little as possible, and the compression maintained, if 
necessary, for several weeks. When the nsevus becomes white, flat, and 
firm, its speedy cure may be expected. This treatment is especially 
applicable to those cases where, from the extent of the disease, opera- 
tive procedure is inapplicable. Dr. Behrend, of Berlin, prefers the 
application of strong acetic acid, followed by compresses soaked in 
vinegar. Under this treatment, the blood is made to coagulate in its 
vessels ; the nsevus becomes hard and yellow, and is thrown off in the 
form of a parchment-like layer by a process of exfoliation. Collodion 
is well suited to effect and assist compression ; but to do any good, the 
compression must be continued for a considerable time. 

Numerous methods besides the above have been suggested from time 
to time for the treatment of vascular naevi, such as exciting inflamma- 
tion of the vascular growth by vaccination ; applying potassa fusa ; 
nitric acid ; injecting them with dilute nitric acid ; passing a seton 
through them; applying the actual cautery; quick -lime ; tartarized 
antimony, &c. 

At the present time I am interested in two cases of vascular naevi 
in children, which have been left alone, and are now undergoing 
spontaneous cure ; and the observation of these cases has led me to 
believe that many of the vascular naevi of infancy would get well if 
left undisturbed. In one of these cases the naevus was round, as 
large as a small hazel-nut, and situated on the scalp, immediately over 
the anterior fontanelle. I intended to remove it by means of the • 
crucial ligature applied around its base, but deferred the operation 
until the closure of the fontanelle should have advanced towards com- 
pletion, inspecting it from time to time, lest any considerable increase 
of growth might render an earlier operation necessary. The naevus 
made its appearance immediately after birth, and the child is now 
nearly a year old. The tumor was vividly red, almost transparent, 
and apparently covered only by a thin cuticle. At my last inspection 
it was whitish, shrivelled, and the integument was considerably 
thickened; spontaneous cure was rapidly progressing. In the other 
case, the naevus was flat, and occupied the shoulder of the child, to the 
extent of nearly an inch square. The only remedy that suggested 



DISEASES OF THE NERVOUS STRUCTURE. 513 

itself was compression, or nitric acid ; but nothing was done. It ap- 
peared at birth, and the child is now two years old; the vascular 
structure has become absorbed in various places; from being vividly 
red, the skin has recovered its whiter tint in several parts, but, on 
close inspection, has a disorganized appearance, somewhat like a 
cicatrix. The curative change is most active in the centre, and 
through one segment of the patch ; the part still remaining active 
being a portion of the border. 



CHAPTER XVII. 

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN. 
DISEASES OF THE NERVOUS STRUCTURE. 

Under the influence of disordered nervous excitability, depending 
sometimes on constitutional and sometimes on local causes, the sensi- 
bility of the skin may be increased to a morbid extent, constituting 
hypercesthesia ; it may also be reduced in sensibility, constituting 
ancesthesia ; or it may be morbidly altered as well as simply augment- 
ed, and give rise to a painful sensation of itching, to which the term 
pruritus has been applied. These disordered conditions of sensation 
are independent of any local disease of the skin, which retains its 
wonted appearance and structure. 

HYPERESTHESIA. 

Ilyperaesthesia, or excessive sensibility of the skin, is more common 
in women than in men, and is generally referable to hysteria. In an 
instance of this disorder, at present under my care, the sensitiveness 
of the skin is so great that the slightest touch with the finger occasions 
pain ; so far as sensibility is concerned, the patient is as though 
Hayed, and utterly incapable of bearing the weight and pressure of 
her ordinary dress. For several weeks she was unable to lie down in 
bed, and at present, though much better, the jolting of a carriage oc- 
casions considerable suffering. In other respects her health is good, 
all the ordinary functions of life being performed regularly and 
properly. In this lady's case there is present a remarkable state of 
swelling of the skin, which comes and goes with the increase or di- 
minution of its sensitiveness. 

ANESTHESIA. 

Anaesthesia, or deficient sensation of the skin, is best illustrated in 
those curious examples of cutaneous disease, namely, morphma alba, 
which have been described under the head of Elephantiasis. In the 



514 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

patches of morphoea alba there is a morbid change in the nervous 
fibrils, and not only the sensation but the nutrition of the skin suffers 
in consequence. Anaesthesia is also met with in a moderate degree 
in those round spots which form upon the scalp and chin, and cause 
destruction of the hair, namely, alopecia areata. The treatment of 
anaesthesia must be determined by the state of constitution of the 
patient, and by the disease with which it is associated. 

PRURITUS. 

Pruritus is sometimes general, but more frequently local; of the latter 
several forms deserve attention. These are — 

Pruritus ani, Pruritus praeputii, 

" scroti, " urethral. 

Pruritus pudendi. 

GENERAL PRURITUS. 

In general pruritus the peripheral extremities of all the cutaneous 
nerves of the body are, in turn, the subject of altered sensation. 
The pruritus is excited by the most trivial causes, and continues 
unabated for hours, depriving the sufferer of every chance of comfort 
and repose. The only period of the day that persons affected with 
this distressing complaint can look forward to for an interval of quiet 
is the morning. As soon as they have taken dinner, or the most 
trifling stimulus, their worrying torment begins. Alteration of tem- 
perature has the same effect; they suffer immediately that they 
change their dress, and especially as soon as they experience the 
warmth of bed. Scratching, instead of relieving, serves only to 
augment the evil, and they are kept in a state of wretched discomfort 
and excitement during the greater part of the night, to forget their 
annoyance at last, only in a sleep made irresistible by absolute 
exhaustion. 

It is interesting to remark the extent to which these painful 
sufferings are subject to the influence of the nervous system. So long 
as the mind is engrossed with agreeable occupation, or is diverted 
from the disorder, the morbid sensation sleeps; but the instant the 
thoughts are turned to the affection the pruritus is aroused, and rages 
with severity. The apprehension of an attack will, in this way, often 
excite it, and every effort for its relief will but prolong its continuance. 

The attacks of general pruritus are variable in length of duration ; 
sometimes they continue for hours without alleviation, while at others 
their periods are shorter, and broken by intervals of calm. The 
disorder may last for several months, and even for years. 

General pruritus is usually the consequence of irritation of one or 
other of the mucous membranes of the body. In some instances, 
the gastro-intestinal mucous membrane is in fault; in others the 
pulmonary mucous membrane; and in others, again, the genito- 
urinary. The affection is sometimes associated with amenorrhoea, or 
dysmenorrhea, and not unfrequently with pregnancy. In some 



DISEASES OF THE NERVOUS STRUCTURE. 515 

instances it is an attendant on jaundice, and is then attributed to the 
presence of bile in the blood. 

PRURITUS AM. 

Pruritus ani is a severe and distressing itching of the mucous 
membrane of the verge of, and immediately within, the anus, and of 
the neighboring integument. The itching is greatest at night, com- 
mencing shortly after the sufferer has retired to bed, and continuing 
for several hours. There is no trace of morbid alteration of the 
skin, but sometimes the parts are excoriated by scratching, and a 
morbid secretion is poured out, which increases the irritation, and 
gives rise to erythema of the surrounding skin. Unless relieved by 
treatment, pruritus ani will continue for many months, and even 
for years. 

The causes of pruritus ani are numerous, being partly referable to 
the state of the constitution, and partly to local irritation. Among 
those of the latter class are, ascarides, hemorrhoidal swellings, fistula, 
and chronic inflammation of the mucous membrane of the rectum. 
The general causes are, sedentary occupation, disordered health, heat 
of weather, irregularities of diet, cessation of catamenia, &c. Dr. 
Lettsom was of opinion, that in certain cases this disease acted as a 
useful counter-irritant, and he records several instances in which 
visceral and cerebral congestions were relieved by its attack. 

PRURITUS SCROTI. 

Pruritus scroti is identical in most respects with the preceding- 
affection, and originates in similar causes. It is usually dependent 
upon the irritating effects of the lithic acid diathesis, upon the 
presence of ascarides in the rectum, or upon a morbid and irritating 
fluid secreted by the abraded skin. In attempts made to relieve the 
pruritus by scratching, painful excoriations are often produced. The 
back of the scrotum is most frequently affected. 

PRURITUS PRjEPUTII. 

This form of pruritus depends upon irritation, usually excited by 
morbid secretion from the mucous membrane of the prepuce. The 
disease originates in neglect, and may be relieved by attention to 
cleanliness and alkaline ablutions. It occurs, for the most part, in 
the summer season, and is very distressing whilst it continues. 

PRURITUS URETHRA. 

Pruritus urethralis occurs at the extremity and along the canal of 
the urethra in females, and gives rise to great discomfort and annoyance. 
This troublesome affection usually depends on some irritation of the 
mucous membrane of the bladder, and is analogous to the pruritus 
which is experienced at the meatus urinarius of the male in calculus 
of the bladder. 



516 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 



PRURITUS PUDENDI. 



Pruritus pudendi is a most distressing affection. It invades chiefly 
the external labia and vulva, but sometimes extends inwards along 
the vagina, giving rise to excessive discomfort, and often exciting 
symptoms of nymphomania. The disease affects all ages : I have 
twice seen it in young children ; more frequently it occurs at the 
period of puberty, or of the cessation of the catamenia. It is sometimes 
a very distressing accompaniment of pregnancy, invading at about 
the fourth month or after parturition. Among other causes which 
have been indicated as originating this disease are ascarides in the 
rectum, hemorrhoids, and varicose veins of the labia or vagina. 

Diagnosis. — Pruritus may be distinguished from prurigo by the 
absence of the alteration in structure which is characteristic of the 
latter disorder ; and from other affections it is at once recognizable by 
the sound state of the skin. 

Treatment. — The treatment of pruritus must be general or local, 
according to the nature of its cause. The general treatment must be 
directed to the regulation of the secretions ; in a debilitated state of the 
system, tonics are indicated, and sedatives are in most cases indis- 
pensable. Arsenic sometimes acts as a specific. The diet should be 
digestible and nutritious, and stimuli avoided. The best local appli- 
cations for soothing the pruritus are, the juniper tar, the sesquicar- 
bonate of ammonia lotion, a solution of acetic acid, lemon-juice min- 
gled with water, or the hydrocyanic acid lotion with emulsion of bitter 
almonds. 

For the local varieties, constitutional treatment is equally necessary 
with local. In pruritus ani, if there be symptoms of congestion of 
the mucous membrane of the bowels, leeches should be applied to the 
verge of the anus, and the region subsequently fomented. If ascarides 
be present, they must be destroyed by a quassia or turpentine enema. 
I have found an opium injection relieve the irritation after all other 
means had failed. The local remedies most serviceable in pruritus 
ani are, juniper tar, either as an ointment, or in combination with 
alcohol ; a weak solution of acetic acid, or bichloride of mercury, 
solution and tincture of opium, creasote, compresses saturated with 
liquor plumbi, the nitrate of mercury ointment, &c. The bichloride 
of mercury is contra-indicated, if there be abrasion of surface. 

Besides the general remedies applicable to pruritus ani, a lotion of 
acetate of lead, of sulphate of zinc, or sponging with the spirituous 
solution of juniper tar, or with the compound tincture of benjamin, 
will be found useful in pruritus scroti. 

Pruritus urethrae may best be relieved by the application of two or 
three leeches to the adjoining mucous membrane, followed by poppy 
fomentations. If these means should fail, cold astringent lotions may 
be tried, or an injection of a weak solution of nitrate of silver. 

Pruritus pudendalis especially requires medication adapted to its 
cause. Where the presence of the foetus in utero is the only apparent 
irritation, we must rely upon the restoration of the secretions and the 
administration of sedatives. If there be heat and dryness of the vulva, 



DISEASES OF THE PAPILLARY STRUCTURE. 517 

symptoms which, indicate congestion of the mucous membrane of the 
vagina, leeches should be applied to the inner surface of the labia, and 
fomentations of poppy-heads, or a cold poultice saturated with liquor 
plumbi, afterwards used. I have employed the juniper v tar, creasote 
lotion, and a solution of the bichloride of mercury with advantage in 
this form of pruritus. Frequent ablutions with tepid water, containing 
a small quantity of sesquicarbonate of ammonia, subcarbonate of soda, 
supersulphate of alumina, or sulphuret of potash, are also beneficial. 
In a very troublesome case, when every other remedy had failed, I suc- 
ceeded in removing the pruritus by the application of a blister upon 
the upper part of the thigh, near the vulva. M. Trousseau praises the 
eifects of injections as warm as the patient can bear; he remarks, that 
he has seen great benefit result from the injection of hot water simply ; 
and that the solution of bichloride of mercury used hot has proved 
successful after years of unavailing attempts with other remedies. 
Lisfranc recommends, that in cases where the pruritus bears relation 
to the menstrual periods, several small bleedings should be practised 
successively, and these, after a few repetitions, he never found to fail. 
He also advises nitrate of silver in the form of lotion and injection. 
The juniper tar ointment considerably diluted is a valuable remedy in 
these cases ; as is also the juniper tar soap. 



CHAPTER XVIII. 

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN. 
DISEASES OF THE PAPILLARY STRUCTURE. 

There are certain abnormal states of the cutaneous textures, the 
external signs of which are, an increase in the growth of the skin 
without any appearance of inflammation. For example, there are 
those prominences which are known by the name of warts, and those 
other thickenings and indurations of the surface of the body which 
are termed callosities and corns. Mason Good gives, as a name to 
these enlargements, ecthyma, 1 or cutaneous excrescence, and his defi- 
nition is, "a superficial, permanent, indolent e.xtuberance, mostly cir- 
cumscribed." The most obvious character of these enlargements is 
the accumulation of epidermis, not diseased epidermis, as in some of 
the preceding affections, but an epidermis in nowise, except thickness, 
differing from that of the rest of the body. Now, the epidermis, it is 
well known, depends for its thickness upon I lie papillary layer of the 
derma, being considerable when the papillary layer is highly de- 
veloped, and vice versd. Hence, an unusual thickening of the epidermis 
is an evidence of an abnormally developed or hypertrophous condition 

1 ix.<pvct, educo, egero. 



518 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

of the papillary layer upon which it is fashioned and rests. This is 
precisely the pathological state of the diseases comprehended in the 
present group. The papillae of the skin are unnaturally enlarged, in 
the case of warts, without any apparent cause ; in the case of corns, 
in consequence of the irritation caused by pressure ; and their enlarge- 
ment is associated with an augmented formation of epidermis. I have 
already had occasion to remark, that in lepra there exists an hypertro- 
phied condition of the papillre of the skin, but the enlargement is 
associated with other morbid conditions, which give a specialty to that 
disease. ' 

There is another form of hypertrophy of the epidermis consequent 
on a previously diseased state of the part of the body upon which it 
occurs, which I have also included in this group, under the name of 
pachulosis. In the first edition of this work, pachulosis was described 
under the title of ichthyosis spuria. 

The diseases included in the present group are, therefore, 

Verruca, Tylosis, 

Clavus, Pachulosis. 

VERRUCA. 

Syn. Ecphyma verruca, Mason Good. Warts. Sessile Warts. 1 Die 
Warze, Germ. 

A wart is a state of hypertrophy of the papillse of the derma, 2 at- 
tended with an increased production of epidermis. (Plate VI., figs. 
1, 2.) Warts are usually of small size, and of a rounded figure, 
verruca simplex; sometimes, however, they appear in the form of 
bands several lines in breadth, and of variable length. They are gene- 
rally insensible, rough to the touch, and their medium projection from 
the surface is about a line. They may be developed at any period of 
life, but are most frequent in children and elderly persons, and arise 
without any apparent cause, to continue for the rest of life, or disap- 
pear unexpectedly. Their usual seat is the hands; less commonly they 
are seen on the trunk of the body, the scalp, or face. 

Hypertrophy of the papillae of the derma in the production of warts 
takes place without apparent cause, and without premonition. The 
papillge, for the extent of a line, more or less, gradually increase in 
length, and constitute a small tuft. Each of these papillte forms 
around itself an epidermal sheath, and these epidermal sheaths are 
held together, in the form of a bundle, by the epidermal mesh formed 

1 Under the name of Verruca achrochordon, a pedunculated wart is described by some 
authors. This is an error; warts, according to the above definition, are hyper-forma- 
tions of epidermis, but the pedunculated warts are invariably productions of the derma, 
and. in many instances, as I have proved, the emptied tegumentary sacs of small seba- 
ceous tumors. 

2 My researches into the structure of warts date as far back as 1830, when my attention 
was directed to their nature by a remarkable bleeding wart, which I had at that time on 
my own finger. Since this period, their structure has been investigated by Ascherson 
{Casper a Wochenschrift, 1830), and more recently by Dr. Gustav Simon, of Berlin (Miiller's 
Arrhiv., 1840). The latter writer speaks doubtingly of their origin in all instances by hy- 
pertrophied papilla, and state- that they arise sometimes where there are no papillae. I 
differ entirely from him in this opinion. 



DISEASES OF THE PAPILLARY STRUCTURE. 519 

between and around them by the bases of the hypertrophiecl and the 
surrounding normal papillae. It very rarely happens that the whole 
of the papillae included by the area of the wart are elongated ; several 
of them retain their natural size, and these contribute to the produc- 
tion of the interfibrous epidermal mesh. 1 "When warts have grown to 
some length, their extremity becomes rough, and their fibrous struc- 
ture is distinctly apparent ; it not unfrequently happens that warts of 
long standing split and break up in the direction of these vertical 
fibres, verruca lobosa. 

The structure of a wart is also shown by making a succession of 
horizontal sections of its mass ; by this means the longest papillae 
will be cut across, and a slight oozing of blood will take place ; and 
if the sections be continued, more and more of the apices of the papillae 
will be divided. The structure of a wart is also well exhibited by thin 
sections cut horizontally and vertically, and examined under the micro- 
scope with a lens of low power. 

Rayer compares warts formed of isolated papillae, very aptly, to 
" coarse plush." He quotes from M. Rennes a remarkable instance of 
a wart of great extent {verruca confluens), and presenting the appear- 
ance of a band : " a band of agglomerated warts, from eight lines to 
an inch in breadth, extended from the upper and anterior part of the 
right side of the breast, underneath the clavicle, along the arm and 
forearm of the same side, till it reached the carpus, where it increased 
considerably in breadth, and finally overspread the whole palm of the 
hand." 

Warts are generally known as isolated growths, or dispersed in 
scanty groups on different parts of the body, but they are sometimes 
met with so numerously as to constitute an eruption of warts. I have 
met with numerous cases of this kind ; in one, a young tradesman, 
about twenty-five years of age, there were some hundreds of small 
warts clustered on the backs of the wrists and hands, and others upon 
the upper part of the forehead. Another example occurred in a girl 
of eighteen, whose hands and wrists on the dorsal aspect were covered 
with these morbid growths. While on the forehead of young women 
they are far from being rare. 

But there is another kind of wart which is by no means uncommon, 
and which, from its appearance, may be termed verruca digitata. This 
wart is found on the scalp, and sometimes exists in that situation in 
considerable numbers. Fixed on the skin of the head, and throwing 
out on all sides its pale, finger-like papillae, it may be mistaken for an 
insect, until its fixed adhesion to the skin and immobility prove the 
contrary. Sometimes the digitated wart is single, or a few only are 
met with ; at other times, they are so numerous as to act as an impe- 
diment to combing the hair. They may be small, consisting of two or 
three digitated papillae only, or large, forming a tuft of hypertrophous 
papillae of considerable size. They are longer than ordinary warts, 
and commonly range from two to four lines in height. 

1 This interfibrous mesh is not present in all warts ; when it is absent, the fibres adhere 
but slightly by means of their surfaces, and are kept together by the thick rim of epidermis 
which surrounds them. 



520 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

Causes. — Warts frequently originate without apparent cause ; 
sometimes they seem to depend on local irritation of the integument ; 
and at other times result from a morbid state of the skin, commonly 
associated with torpor of function. Some persons exhibit an especial 
predisposition to the development of these productions. It is popu- 
larly believed that the blood proceeding from warts is capable of ex- 
citing their growth in unaffected persons. Such a supposition is too 
absurd to deserve further attention. 

Treatment. — When warts are isolated, they may be removed by 
a caustic, but when they are numerous, they call for constitutional 
treatment. The best caustic for their removal is the potassa fuaa, 
which requires to be used with care, and could not be safely trusted 
out of the hands of the medical man. Other caustics, which may be 
employed for a similar purpose, are, nitric acid, strong acetic acid, 
tincture of iodine, and the nitrate of silver. But the potassa fusa 
surpasses all these in removing the wart at once and completely, while 
at the same time it sets up sufficient inflammation to destroy the en- 
larged papillae, and modify the structure of the derma. If too much 
inflammation be created, the part should be covered with a piece of 
Alison's lambskin saturated with water, with water-dressing, or a 
poultice. When other caustics than the potassa fusa are used, they 
harden and dry the epidermis, and the dried and hardened part re- 
quires paring each time that the caustic is repeated ; with the potassa 
fusa no such elaborate process is needed. 1 For the digitated warts on 
the scalp, the potassa fusa is the best remedy, and the plan is, to 
soften them, and rub them away with a point of potassa fusa, while 
the patient is under operation. When removed in this manner, they 
rarely return. 

But while the caustic removes the local disease, it is clear that it- 
does nothing towards correcting the disposition in the system to the 
reproduction of warts ; and, therefore, where they are numerous, and 
a verrucous constitution may be said to exist, it becomes necessary to 
have recourse to a constitutional treatment. For this purpose, I 
have prescribed arsenic with the greatest success, and it is curious to 
see with what rapidity the skin responds to the action of this medi- 
cine, and how rapidly an eruption of warts, apparently so little 
amenable to constitutional remedies, will disperse. I lately treated a 
young lady in Cumberland, whom I had not the advantage of seeing, 
in this way, and with complete success. She took the arseniate of 
soda for a brief period only, a few weeks, and pencilled the warts, 
which were of the digitated kind, and developed on the scalp, with a 
strong solution of the bichloride of mercury. 

Other and less efficient remedies for warts are, the juice of the cheli- 
donium majus, strong pyroligneous or acetic acid, the mineral acids, 
liquor potassae, liquor ammonia, and the muriate of ammonia. The 
last is the safest and most manageable, and, Avith perseverance, is coui- 

1 Mason Good observes that in Sweden warts are " destroyed by the Gryllus verrucivorus, 
or wart-eating grasshopper, with iireen wings spotted with brown. The common people 

catch it for this purpose; and it is said to operate by biting off the excrescence, and dis- 
charging a corrosive liquor on the wound.'' 



DISEASES OF THE PAPILLARY STRUCTURE. 521 

nionly successful, requiring to be rubbed upon the wart night and 
morning for some weeks. 

Plumbe recommends the use of a small piece of blistering plaster 
laid on the crown of the wart, and covered by an adhesive strap. In 
the country, the juice of the chelidonium majus is a popular remedy. 

CLAVDS. TYLOSIS. 

Syn. Corns. Callosities. 

A corn is an increased degree of thickness of the epidermis, result- 
ing from hypertrophy of the papillae of the derma ; this hypertrophy 
being determined and kept up by the irritation caused by undue pres- 
sure and friction on the part affected. So long as the causes which 
first gave existence to the corn continue, the epidermis accumulates, 
and, by its pressure on the vascular derma may give rise to ulterior 
and serious consequences. But as soon as the pressure and friction 
are removed, the derma regains its natural state, and the epidermis 
ceases to be produced in abnormal quantity. The ordinary seat of 
corns is the feet ; they may, however, be developed on every part of 
the body. 

Corns present us with three modifications in relation to structure 
and degree, which may be considered as varieties ; they are, laminated 
corns, fibrous corns, and soft corns. 

LAMINATED CORNS. 

Syn. Tylosis. Callus. Callosity. Die Schioulle, Germ. 

Investigating the manner of development and growth of a corn, we 
find that, wherever a portion of skin is pressed and rubbed by a hard 
and irritating substance, as in the case of the integument of the foot by 
the shoe, and particularly when the part itself is unable to yield suffi- 
ciently, in consequence of its seat over a bone, to escape the pressure 
or friction, the vascular rete of the derma becomes congested. If the 
process were now to cease, the congestion of the derma would subside 
and the skin gradually return to its natural state. But instead of 
ceasing, the pressure and friction are continued from time to time, and 
for some hours together, for months and years ; the derma becomes 
more and more habitually congested, and the papillae are at first tem- 
porarily, and afterwards permanently enlarged, the lengthening of the 
papillae being most considerable in the centre, where the greatest 
amount of pressure exists. 

The enlargement or hypertrophy of the papillae of the derma is a 
perfectly natural process, and the mere result of excitation of the 
cutaneous nerves in the first instance, seconded by vascular determi- 
nation to the part, and subsequently increased vascularity, with the 
associated consequence, augmented nutrition. With hypertrophy of 
the papillae, the function of these organs is likewise increased, and a 
proportion <>(' epidermis corresponding with the enlarged papillae is 
produced. The formation of this epidermis over the hypertrophied 
papillae constitutes a callosity, or corn, and the thickness of the corn 
bears an exact relation to the thickness of the epidermis of the sur- 



522 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

rounding skin, plus the increased dimensions and vascularity of the 
formative papillae. 

This is the mode of formation of every corn, and this the structure 
which all newly -formed and moderately sized corns present. It follows, 
from this description, that if we make a vertical section of such a corn, 
and examine the cut surface with a lens, we shall find the epidermal 
thickening perfectly homogeneous, and this is the general fact. Some- 
times, however, it happens that the section of the corn presents a dis- 
tinctly stratified texture, and the successive laminae differ from each 
other in color. I have seen the laminae presenting the various tints 
of light brown, dark brown, and even black. This peculiarity of 
structure is easily explained. A more violent pressure than usual, 
such as that produced by a new boot, or an unusually long walk, 
upon the enlarged papillEe, has caused an effusion of blood beneath 
the epidermis, or among the epidermal cells. A new formation of 
epidermis carries this ecchymosed part towards the surface, and it is 
seen on the face of a section as a dark lamina. Minor degrees of 
pressure will give rise to lesser sanguineous effusions, and consequently 
to lighter colored or thinner laminae, and, moreover, the effused and 
desiccated blood will lose a considerable proportion of its color as it 
approaches the surface. 

FIBROUS CORNS. 

Syn. Clavus. Die Huneraug, Germ. 

The preceding is a sketch of the history of the common laminated 
corn, or callus, but those who have paid attention to the subject will 
have observed in certain corns something more than this. On the 
summit of the corn they will have remarked an appearance resem- 
bling the ends of fibres ; in cutting the summit horizontally, there is 
an appearance as though these vertical fibres were cut across (eye of 
the corn), and they may possibly associate with this appearance the 
popular belief in the existence of a core and root to the corn. If a 
vertical and central section be made of a corn of this kind, the exis- 
tence of vertical fibres, generally slightly different in tint of color from 
the homogeneous epidermis, and frequently intermingled with traces 
of opaque white, is distinctly demonstrated. The explanation of this 
appearance is as follows : 

The continuance of pressure on the central part of the convexity of 
the corn causes undue pressure on the derma, and the common result 
of pressure on a soft part ensues, the papillae are absorbed, next the 
entire structure of the derma is thinned, and, after a time, even the 
tissues below the derma are injured by the compression. The part 
of the derma which in the early stages of the corn was more convex 
than the rest, now becomes depressed, and instead of being a promi- 
nence, is a hollow cup of greater or less depth. We have, therefore, 
two conditions present in the derma, the bearing of which on the 
production of the superjacent epidermis is now to be considered. The 
derma being thinned almost to the state of atrophy, and the papillae 
removed by absorption, the epidermis is necessarily altered in structure ; 
it becomes horny and of a deeper color than the surrounding cuticle. 



DISEASES OF THE PAPILLARY STRUCTURE. 523 

In the second place, the secreting surface having lost its plane position 
and become concave, the epidermis is altered in direction, and the 
continuity between the cup-shaped layers corresponding with the 
depression of the derma, and those of the plane surface around, is 
disturbed. It is this alteration of direction, and the uprising of the 
edges of the layers corresponding with the rim of the cup on the 
surface of the corn, which produces the appearance of fibres ; the whole 
mass of altered epidermis constituting the core of the corn. 

The art of the chiropodist consists in dislodging the core of the 
corn from its concave bed, and when this is done, it is no uncommon 
thing to find a drop of serum or pus, and sometimes extravasated 
blood beneath its. deepest part. When these fluids are removed, the 
surface of the derma, congested and tender, is seen to be exposed. 

The description of a corn which I have now given appertains to 
one of long standing ; in those of more recent formation every degree 
of transition may be observed, from the simply congested and hyper- 
trophous condition of the papillae to their progressive and total 
absorption. The structure of the core of the corn is often apparent 
on its surface from the gradual wearing away of its summit ; this 
process being equivalent to a horizontal section. 

Corns sometimes give rise to serious consequences ; by pressure 
on bursse they produce bunions ; when seated on joints they often 
excite inflammation of the structures entering into the formation of 
the articulation, exostosis of bones, &c. I once dissected a corn situ- 
ated on the metacarpo-phalangeal articulation of the little toe, which 
had made its way into the joint, and had produced absorption of the 
articulating ends of both bones. 

SOFT CORNS. 

These productions are exceedingly painful and annoying, and more 
troublesome than the two preceding varieties. They occur between 
the toes, are always of small size, present little or no convexity on 
the surface, and, from being constantly immersed in the perspiratory 
secretion which collects in the situation of their growth, they are soft 
to the impression of the knife. 

In manner of formation and growth, soft corns are identical with 
the preceding. From the pressure of the toes one against another, 
some point of the skin, either corresponding with or on the soft parts 
immediately opposite the prominent head of a phalangeal bone, 
becomes slightly inflamed, and a greater thickness of epidermis than 
usual is formed. At this stage of growth of the corn, it frequently 
happens that an increase of irritation gives rise to effusion of a serous 
fluid beneath the white and thickened epidermis. The epidermis is 
rendered soft by saturation with the fluid, and a small aperture is 
formed in the centre of the disk, through which the serum escapes. 
I have seen a soft corn remain for several months in this state during 
the summer season, the surface of the derma continuing to secrete 
scrum, and the serum being retained, or escaping through the small 
central aperture. At other times, and when the irritation is less 
severe, the epidermis is thickened by the addition of fresh epidermal 



524 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

formations to its under surface, until a convex mass is formed, which, 
by pressure on the papillae of the derma, effects their absorption, and 
puts a stop to the continuance of the formative process. If a soft 
corn be extracted at this period, it will be found to be plano-convex, 
the plane surface corresponding with the level of the adjacent epider- 
mis of the toe, and the convex surface projecting more or less deeply 
into the derma. 

The soft corn sometimes gives rise to the formation of an ulcer, 
and being separated from the adjacent tissues by suppuration is 
thrown off. In one case I saw a sinuous ulcer, excited by a soft corn, 
extend as far as the phalanx ; it was followed by exfoliation of the 
surface of the bone, and a permanent stiffness of the joint. 

Causes. — The causes of corns are pressure and friction. They 
occur at all periods of life, and under various circumstances. On the 
feet they are usually produced by the friction and pressure of shoes 
or boots, which are either too tight or too loose. Between the toes 
they result from pressure of these members against one another. 
They may also be the consequence of club-foot, where parts of the 
skin unused to pressure are made to support the weight of the body. 
On the hands, corns are met with as a consequence of the pressure or 
friction of tools in certain trades ; of the oar in rowing. On the 
knees they result from much kneeling ; and are also found on various 
other parts of the body. 

Treatment. — The treatment of corns offers two indications, one 
curative, the other palliative. The first consists in the removal of 
the cause, namely, pressure and friction ; and the latter in pruning, 
from time to time, the horny growth. The first indication may be 
fulfilled, where practicable, by rest and disuse of the article of dress 
which occasioned the affection ; or by means of plasters of thick soft 
leather, perforated in the centre by a round aperture r that fits the 
summit of the corn, and relieves it from pressure. Plasters of amadou 
are well adapted for this purpose. The palliative treatment consists 
in the removal of the thickened epidermis either by scraping or filing, 
after the corns have been well soaked and softened in an alkaline 
solution ; or by cutting, either in the soft or the hard state. The 
chiropodists dissect out the central part of the corn, the eye or root, 
as they term it, by a patient process of cutting and tearing, leaving 
the circumference to serve as a circular cushion of protection to the 
more tender, central part. 

Other modes of removing the epidermis, are, by nitrate of silver, 
by plasters containing the solvents of albumen, namely, soda and 
potash, &c. It should, however, be recollected that the formation of 
a corn is not a morbid process, but simply an augmentation of a 
natural function, kept up by irritation. 

The only cure for the soft corn is its entire removal. This may 
most easily be accomplished by the help of a pair of scissors ; all the 
thickened epidermis being taken away at the same time. The forma- 
tion of soft corns may be prevented, and when present they may be 
rendered bearable, by daily ablution with soap, and by placing a 
piece of cotton-wool between the toes after each ablution. 



DISEASES OF THE PIGMENTARY STRUCTURE. 525 



PACHULOSIS. 

After certain chronic affections, in which the skin is secondarily in- 
volved, particularly that of the lower extremities, the epidermis is pro- 
duced in abnormal quantity ; it becomes thick, dry, and harsh, and 
cracks into scales of irregular form and size. This appearance of the 
skin has been admitted by Willan into his description of ichthyosis, 
and referred to by other writers, under the title of accidental ichthyo- 
sis, but it is quite clear, from the description of ichthyosis given in the 
chapter on the diseases of the sebiparous system, that the present dis- 
order bears no relation to that affection. As an inordinate produc- 
tion of epidermis dependent on hypertrophy of the papillse of the skin, 
it has a title to a place in this group, while its principal character, 
namely, that of thickening and condensation of the skin, seems to 
point to pachulosis (^a/<k, crassitudo) as a fitting designation. 

This state of the skin occurs for the most part in elderly persons, 
and not unfrequently after the healing up of an old ulcer of the leg. 
I have also seen it follow some lasting cutaneous disorders, such as 
chronic eczema. It is sometimes a sequela of anasarca. 

Treatment. — The treatment of pachulosis consists in sponging the 
scaly surface with a damp sponge, dipped in fine oatmeal, diligently, 
for five or ten minutes, and then anointing the surface with a liniment 
of lime-water and oil; adding to this liniment as the torpor of the skin 
gradually yields, a few drops of liquor ammonite. In the course of a 
short time, the natural tone of the skin may generally be restored by 
this treatment. Another mode of treatment, is to remove as much of 
the hardened coating as possible with soap, then cover it up with a 
plaster of diachylon softened by melting with an equal proportion of 
almond-oil, and bind it closely to the skin with an elastic bandage. 
The dressing^should be repeated every second day ; and every time 
the plaster is removed the diseased surface should be well washed 
with soap. This process should be continued until the whole of the 
hardened cuticle is cleared away, and the skin brought into a healthy 
state. 



CHAPTER XIX. 

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN. 
DISEASES OF THE PIGMENTARY STRUCTURE. 

Under this head, corresponding with the order maculae of Willan, 
EPIOHROSIS of Mason Good, or Dyschroma, are assembled those affec- 
tions of the cutaneous textures which are characterized by discolora- 
tion of the skin. The precise seat of these alterations is the rete mu- 
cosum and papillary layer of the derma. The cause may be referred 
to three principal conditions : firstly, the original organization of the 
individual ; secondly, alteration of function of the derma without ap- 



526 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

parent change of structure ; and thirdly, alteration of nutrition of the 
epidermal cells of the rete mucosum. 

Maculae may be arranged in three principal groups, namely, those 
which are characterized by augmentation of the natural pigment of the 
rete mucosum ; those in which there is diminution of pigment ; and 
those which present a morbid alteration of pigment. To these charac- 
ters, which are indicative of important differences, both as regards 
quantity and kind, in the natural pigment of the skin, I propose to 
add a fourth group, with a view of including that remarkable altera- 
tion in the color of the skin which is produced by the internal use of 
nitrate of silver. The seat of this discoloration is different from the 
preceding, inasmuch as it occupies the papillary layer of the derma, 
and may very properly be considered under the designation of chemi- 
cal coloration of the skin. 

I. AUGMENTATION OF PIGMENT. 
MELANOPATHIA. 

Nigrities. Nigredo cutis. Die Schivarze ffaut, Germ. 

When we compare the distribution of the pigment of the skin 
throughout the members of the human family, we are struck with two 
remarkable extremes of difference, as illustrated in the jetty black of 
the tropical zone, and the fair complexion of the natives of colder cli- 
mates. Between these extremes every shade of tint may be found 
in intermediate latitudes ; and, indeed, by the alteration of the solar 
influence only, the pigment may be increased in those of fair skin, and 
on the other hand, may be diminished in the dark to a very conside- 
rable extent ; but we require to proceed no further than our own 
hearths for an illustration of the fact, that the fair complexion may be 
rendered dark by the stimulation of light during the summer months, 
and the quantity of pigment will be again reduced during the winter 
season. To state this fact in physiological language, the activity of 
the functions of the skin is increased during the summer, and under 
the stimulus of the sun ; while in the winter season it is diminished to 
its minimum. One of the functions of the skin is the formation of 
pigment ; and, under the stimulus of light and heat, and of the sun's 
rays, this function is greatly augmented, and the skin, consequently, 
assumes a darker tint. 

But it is scarcely necessary to remark that the phenomena involved 
in the functions of the skin are not wholly referable to external 
agencies. That which the stimulus of light and of the sun's rays is 
to the skin, under natural circumstances, the stimulus of morbid ac- 
tion may be in a disordered state of the system. Hence, we occasion- 
ally meet with instances in which the skin is altered in its color in a 
brief period of time, either temporarily or permanently, as one of the 
consequences of disease, this alteration being confined to a limited 
region, or being more or less generally diffused over a large surface. 

Again, it is clear that especial organization must also contribute 
very largely to the differences of tint which are observed in the 



DISEASES OF THE PIGMENTARY STRUCTURE. 527 

human race. The long winter of the colder climates, or protracted im- 
prisonment in a darkened cell, would not blanch the skin of the negro 
any more than would the long blaze of light, and the intense heat of 
the torrid zone, confer upon the skin of the European the rich jet of 
the native African. We are yet to learn how far colonization for a 
number of years would give rise to these results. It is to especial 
organization that we must have recourse, to explain the great differ- 
ence in shade of color that exists among the inhabitants of the same 
island, and the differences which we often meet with in different parts 
of the body of the same individual. In persons of dark complexion, 
certain parts of the cutaneous surface always present a deeper tint than 
the rest. One of the natural changes occurring at puberty, is the 
alteration of the skin of the sexual apparatus to a brown color, more 
or less deep in different individuals, while in rare instances, the skin 
in this region presents a deep black. Haller, in his Physiology, 
relates a case of this kind. The alteration of color which takes place 
in the areola around the nipple of pregnant women is an analogous 
change. In some persons the cutaneous pigment in the genital 
region is partial in its distribution, and appears in the form of patches 
of various size. Again, patches of a darker color than the surround- 
ing^kin, but identical in every other respect, may be developed upon 
any part of the surface of the integument in individuals of every 
shade of complexion. Plenck seems to be under the belief that the 
Tartars have naturally a mottled skin : " Cutis variegata nativa ; in 
Tartarorum gente tigridis instar;" while of another variety of Maculae 
cutus, namely, "cutis variegata morbosa," he observes, "Visa est ad 
semel in uno subjecto facies viridis, latus corporis dextrum nigrum, 
et sinistrum flavum." 

The alteration of color which takes place around the nipple of 
pregnant women, is a curious physiological change, but one which 
comes so constantly before our eyes, as to meet with little attention. 
This deepening of color corresponds with that part of the skin of the 
breast which is termed the areola, but occasionally, nature makes one 
of those singular aberrations from her ordinary laws, that stimulate 
our curiosity and interest. Such was the case in the following nar- 
rative, communicated to me by Mr. Jackson, of High Wycombe, 
Buckinghamshire. " Martha Weston, aged eighteen, came into the 
Union House in June, 1843, to be confined, being the last month 
of her first pregnancy. My attention was directed to her by the 
matron, in consequence of an unusual darkness of the skin. Upon 
examination, I found the anterior surface of the body from the cla- 
vicles, downwards to about the middle of the thighs, of a negro 
blackness. 

"From the girl's statement I learned that, shortly after she became 
pregnant, the areola around each nipple looked very dark, but no 
further perceptible change took place until she quickened, when an 
evident darkness of the whole breast was visible, extending upwards 
to the throat, and downwards to the thighs, gradually assuming a 
deep black color. Over the hips it extended laterally, but no part of 
the posterior surface of the body was affected. Her complexion was 



528 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

naturally rather dark, with black hair and eyes. Her health had 
been always good, neither had she experienced more than the usual 
degree of irritation resulting from pregnancy. At her labor, I was 
called in by the midwife to the Institution, in consequence of a pre- 
sentation of the hand and umbilicus ; turning was resorted to, and the 
girl did well. She left the house a month after her confinement, at 
which time there was no alteration in the blackness of the skin ; but 
on my last meeting her, about a year afterwards, she assured me it 
had entirely disappeared." 

The following interesting case of general melanopathia was com- 
municated to me by the late Dr. Pereira. 

"John Daniels, aged seventeen, weaver, applied at the London 
Hospital, on account of the dark color of his skin. He states that for 
some months past he has been changing color and becoming darker ; 
and that his companions have annoyed him by saying that he is 
changing to a negro. His appearance is that of a dark-colored gipsy. 
The darkness of the skin, though general over the body, was most 
marked at the nape of the neck, and least so on the nose and upper 
lip. His hair is light-colored, and his eyes gray ; these, his mother 
states, have undergone no change during the alteration of the color of 
the skin. His mother is remarkably fair, and she tells me that .his 
father is equally so; and that, until about fifteen months ago, the son 
was considered very fair. The darkening commenced in the summer ; 
but the boy had not been particularly exposed to the sun prior to the 
change. He worked with his father at weaving, principally of black 
goods. The tint of the skin was brown, and in this respect differed 
from the slate-color induced by the use of nitrate of silver. It some- 
what resembled that which I have seen induced by the inhalation of 
arseniuretted hydrogen ; but in the latter case the sclerotic coat of 
the eye was discolored ; whereas, in Daniels's case, the sclerotica was 
remarkably white. 

" I carefully questioned both the boy and his mother as to the use 
of medicine, or of any other agent which could have induced this 
change of color in the skin, but without avail. The boy had taken 
no medicine, and, to the knowledge of himself and mother, had been 
subjected to no deleterious influences. The color obviously depended 
on some alteration in the quantity or quality of the coloring matter of 
the skin. It could not depend on the presence of any coloring matter 
in the blood, since neither the conjunctiva nor the mucous membrane 
of the mouth was altered in color. The total absence of desquamation 
and itching readily distinguished the case from melasma (Pityriasis 
nigra). A blister was applied to the nape of the neck. After it had 
caused vesication, it was obvious that the dark color of the skin re- 
sided in the derma, and not in the cuticle. The mother states that 
the intensity of the color is not always alike, being sometimes much 
greater than at others. No great hopes being held out that medicine 
would affect the change going on, the boy ceased to attend the hos- 
pital after a few weeks." 

In a case of melanopathia which I had an opportunity of seeing, 
through the courtesy of Mr. Acret, of Torrington Square, the black- 



DISEASES OF THE PIGMENTARY STRUCTURE. 529 

ness affected the entire skin, with the exception of the feet and legs 
as high as the calf. The subject of this curious affection was a young 
woman, twenty-eight years of age, who had enjoyed good health up 
to the first of December, 1844. At this date, she suddenly felt unwell, 
and suffering from nausea, took an antimonial emetic, which failed to 
procure vomiting. She was then attacked with typhus fever, and was 
seriously ill for somewhat more than a month, being unable, during 
the greater part of that period, to sleep, and being frequently delirious. 
Previous to the illness, menstruation was regular and the menses co- 
pious; but since her recovery, she has suffered from amenorrhoea, with 
much periodical pain, until the last three months. Her health at 
present is what she styles "good," that is, her strength is not impaired, 
but she is liable to headache, has an eczematous eruption on the scalp, 
and a dainty appetite. 

It was on her recovery from the above illness that the change of 
color in the skin was first observed. Her hair and eyes are black, 
and her complexion was originally that of a brunette; but she has 
now the color of an East Indian. The darkest parts of her body are, 
the back of the trunk, and the backs of the hands and arms. On 
the face, the red tint of the cheeks blended with the black, and the 
yellow of the forehead and nose struggling for mastery with the deeper 
tint, gave her complexion a singularly Indian appearance. And the 
peculiarity of her color is heightened by the extension of the black- 
ness to her lips, and in patches to the mucous membrane of the mouth. 
Even the teeth have a bluish tint, the lips and teeth seeming as if 
stained by the eating of black cherries. The sclerotic coat of the 
eyeball is brilliantly white. 

On close inspection of the skin, the blackness is seen to be not 
perfectly uniform ; there are small patches in which the depth of color 
is greater than in others, the darker-colored spots corresponding with 
the apertures of follicles. The areola of the nipples approached in 
depth of color to a negro-blackness. 

Another case, communicated to me by the late Dr. Sarti, was as 
follows : Pietro Nanni, a peasant, of St. Martino al Castagna, fifty 
years of age, having unluckily got into a fray, was fired upon and put 
in danger of his life. The shock caused a severe illness, and three 
months- afterwards his skin gradually darkened, until it became quite 
black. The change was first perceived on his cheeks, and thence 
extended over the entire body, being greatest on the front and sides of 
his breast, the inner sides of his legs, and the hands. With the 
termination of this case I am not acquainted. 

Dr. Addison 1 has lately called the attention of the profession to the 
association of melanopathia with disease of the suprarenal capsules, 
and has adduced several examples of this union, of which the follow- 
ing are the most striking. A baker, aged thirty-two, ill for three 
years, had, during that period, two attacks of obstinate cough, 
accompanied with extreme weakness. After the cessation of the 

1 On the constitutional and local effects of diseases of the suprarenal capsules : by Thomas 
Addison, M.D. 4to. 1855. 

34 



530 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

cough, the first time, his skin, previously white, began to darken; at 
the end of the three years, it was so dark that he had the appearance 
of being descended from colored parents. " The cheeks are a little 
sunken, the nose is pointed, the conjunctivae are of a pearly white- 
ness; the voice is puny and puerile." " He complains of a sense of 
soreness in the chest, about the ; scrobiculus cordis." There was no fault 
about the urine, and Dr. Golding Bird, under whose care he was, 
considered the case to be one of anaemia. He died, soon after these 
observations were made, of "acute pericarditis and pulmonic inflam- 
mation." On examination after death, besides disease of the lungs 
and pericardium, and a fragile state of the liver and spleen, the 
kidneys being healthy, "the suprarenal capsules were diseased on both 
sides, the left about the size of a hen's egg, with the head of the 
pancreas firmly tied down to it by adhesions. Both capsules were as 
hard as stones." Dr. Addison concludes from this case, that "the slow 
and gradual inroads of the disease, and the remarkable excess of 
pigment, were sufficiently accounted for by the universality of the 
change that had taken place in the structure of both capsules." 

A tide-waiter, aged thirty-two, of bilious temperament, having 
dark hair and a sallow complexion, was observed during the last six 
months of his life, to be growing gradually dusky in complexion, until 
he became of a dark olive brown color; and black pigmentary patches 
were developed on the mucous membrane of the insides of the lips. 
His duties were anxious, and exposed him to alternations of weather ; 
but, with the exception of an attack of rheumatism and occasional 
bilious vomitings, he had enjoyed good health until six months since, 
when he was seized with a bilious attack of greater violence than 
usual. On this occasion, the vomiting, headache, and constipation 
were succeeded by delirium and temporary insensibility, these latter 
being followed by numbness and loss of power of the fingers and 
legs, and extreme debility, which continued for some weeks. Three 
months later he returned to his duties, but was again laid up with 
headache, vomiting, and constipation ; and two months after this, was 
admitted into Guy's Hospital, where he died after twenty-seven days. 
His symptoms while in hospital, under the care of Dr. Gull, were, 
extreme physical depression and debility, sickness with vomitings of 
mucus, containing a little altered blood; tenderness of epigastrium, 
constipation, clear tongue, cool skin, natural urine, small and feeble 
pulse, and anxiety of countenance. After death, the suprarenal 
capsules were found to contain "compact fibrinous concretions," 
which, " superficially examined, were not unlike some forms of 
strumous tubercle." "The brain, lungs, heart, spleen, liver, and 
kidneys, were normal, but the mucous membrane of the stomach gave 
evidence of subacute gastritis." 

A carpenter, twenty-six years of age, of strumous constitution and 
intemperate habits, had observed during the four months which 
preceded his death, black patches of discoloration upon the mucous 
membrane of his lips, a general change in his complexion to a 
yellowish and olive hue, and patches of black upon the face and in 
the axillae. He had enjoyed good health until six months before 



DISEASES OF THE PIGMENTARY STRUCTURE. 531 

death, when he was attacked with pains in the right leg, extending 
upwards to his back, and resulting in disease of the upper three lum- 
bar vertebrae and lumbar abscess. He died twenty-seven days after 
admission into hospital, his death being preceded by extreme debility, 
torpor, sickness of stomach, hiccough, and typhoid symptoms. Dr. 
Rees, under whose care he was during part of his illness, found " white 
corpuscles" in his blood; after death, besides strumous deposits in the 
lungs, the suprarenal capsules were found " completely destroyed, and 
converted into a mass of strumous disease, the latter of all degrees of 
consistency." 

The inference which is drawn from these cases, is, that whenever 
melanopathia of the skin, in conjunction with extreme prostration of 
the physical powers and anaemia, exists, without other perceptible 
cause, disease of the suprarenal capsules will be found after death. 
The kind of disease of these organs seems to present considerable 
variety, for of eleven cases recorded by Dr. Addison, both capsules 
were diseased in seven, and one only in four. Of the forms of 
disease, one was atrophy from inflammation ; one, enlargement with 
induration ; one, deposits of compact fibrinous concretions ; four, 
scrofulous deposits ; and four, malignant deposits. Dr. Addison 
expresses his "belief that the urgency of the symptoms, and the 
quick or slow progress of the disease, are determined by the activity 
or rapidity of the morbid change going on in the capsules, and by the 
actual amount or degree of that change ; and that universal disease 
of both capsules will, in all probability, be found to prove uniformly 
fatal." This opinion does not appear to be borne out with accuracy 
by the evidence of his cases, for, of the total eleven cases now 
referred to, the period of duration of the disease as ascertained in 
seven, ranges as follows : three years, one year, six months, four 
months, three months, two months. The four longest periods are 
those which correspond with disease of both capsules ; the three 
shortest, namely, from four months to two months, with disease of 
one capsule only. The order of fatality as respects the nature of the 
disease was as follows : three years, enlarged and indurated ; one 
year, enlarged and indurated, with tubercular deposit ; six months, 
fibrinous concretions ; four months, softened strumous deposits ; four 
months, atrophy from inflammation ; three months, malignant deposit 
in one capsule ; two months, tubercular deposit in one capsule. 

The subject, however, is in the infancy of its research, and we must 
accept Dr. Addison's observations as a valuable contribution to 
medicine, and as a basis for further investigation. It cannot be 
allowed that all cases of melanopathia are also examples of disease of 
the suprarenal capsules, any more than that every case of disease of 
the suprarenal capsules must be necessarily accompanied by the 
deposit of a dark pigment in the skin. Dr. Addison has very 
properly shown that melanopathia is only one of the symptoms, of a 
series of tliose which constitute the peculiar form of anaemia which 
he so forcibly describes. " For a long period," he writes, " I had, 
from time to time, met with a very remarkable form of general 
anaemia, occurring without any discoverable cause whatever ; cases 



532 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

in which there hud been no previous loss of blood, no exhausting 
diarrhoea, no chlorosis, no purpura, no renal, splenic, miasmatic, 
glandular, strumous, or malignant disease." "The disease presented 
in every instance the same general character, pursued a similar 
course, and, with scarcely a single exception, was followed, after a 
variable period, by the same fatal result. It occurs in both sexes, 
generally, but not exclusively, beyond the middle period of life, and 
so far as I at present know, chiefly in persons of a somewhat large and 
bulky frame, and with a strongly marked tendency to the formation 
of fat. It makes its approach in so slow and insidious a manner, 
that the patient can hardly fix a date to his earliest feeling of that 
languor, which is shortly to become so extreme. The countenance 
gets pale, the whites of the eyes become pearly, the general frame 
flabby rather than wasted ; the pulse, perhaps, large, but remarkably 
soft and compressible, and occasionally with a slight jerk, especially 
under the slightest excitement ; there is an increasing indisposition to 
exertion, with an uncomfortable feeling of faintness or breathlessness 
on attempting it ; the heart is readily made to palpitate ; the whole 
surface of the body presents a blanched, smooth, and waxy appear- 
ance ; the lips, gums, and tongue, seem bloodless ; the flabbiness of 
the solids increases ; the appetite fails ; extreme languor and faintness 
supervene, breathlessness and palpitations being produced by the 
most trifling exertion or emotion ; some slight oedema is probably 
perceived about the ankles ; the debility becomes extreme, the patient 
can no longer rise from his bed, the mind occasionally wanders, he 
falls into a prostrate and half-torpid state, and at length expires." 
"The leading and characteristic features of the morbid state," are, 
anaemia, general languor and debility, remarkable feebleness of the 
heart's action, irritability of the stomach, and a peculiar change of color 
in the skin, occurring in connection with a diseased condition of the 
"suprarenal capsules." Furthermore, "the great distinctive mark of 
this form of anaemia is the singular dingy or dark discoloration of 
the skin;" "a dark, dingy, or smoky-looking discoloration of the 
integument." And Dr. Addison records his belief, that " the disease 
is by no means of very rare occurrence." 

Returning now to the three cases of melanopathia, narrated by me, 
with the view of ascertaining how far they accord with Dr. Addison's 
description, it will be evident that my first case, that of Martha Wes- 
ton, must be looked upon merely as a physiological phenomenon. In 
the second case (John Daniels), Dr. Pereira speaks of the sclerotica as 
being remarkably white, but does not otherwise lead us to infer the 
existence of anaemia, or any constitutional disease ; the discoloration 
hail been in existence fifteen months when it came under his observa- 
tion. The patient, in the third case, was decidedly anaemic, and the 
subject of some obscure organic disease which may have been that of 
the capsukie suprarenales ; I regret, however, that I am unable to 
report her present state ; she had been two years undergoing a gradual 
change of color, and, according to Dr. Addison's views, ought by this 
time to be dead. 

According to Dr. Addison, disease of the capsulse suprarenales is 



DISEASES OF THE PIGMENTARY STRUCTURE. 533 

attended with disturbance of the chromatogenous function of the skin, 
such disturbance tending to the production of an excess of black pig- 
ment. Upon the announcement of this proposition, we naturally 
inquire whether these organs, which have heretofore been considered 
of so little importance to the well-being of man, which we have been 
taught to look upon as mere vestiges of an organ that had fulfilled its 
office, and was no longer of any use, are really so influential in the 
economy of man, that a mere state of atrophy, or a tuberculous con- 
dition of one of them, is sufficient to set up a series of remarkable 
symptoms which result in the death of the individual in four months 
in one case, in one month in the other ; and which possess the singular 
power of causing the development of an excess of pigmentary matter, 
the latter being not merely limited to the skin and mucous membrane, 
but in one case presenting itself as a true' melanosis, " scattered in small 
masses over the omentum, the mesentery, and the cellular tissue on the 
interior of the abdominal parietes." In taking this view of the supra- 
renal capsules, we must not overlook their intimate relation with the 
great abdominal centre of the organic system of nerves, nor shut out 
from oar minds the probable effects upon that centre of a disease which 
will necessarily involve many of its filaments ; which, in one case, at 
least, had extended to the semilunar ganglion, and produced fatty 
degeneration of a portion of that ganglion and of the adjacent plexus, 
and which, by producing irritation and probably disease of that plexus, 
might lay the foundation for those gastric symptoms, and that state 
of physical prostration and anaemia to which Dr. Addison refers. 
Admitting all this, we have, as an explanation of the phenomena indi- 
cated by Dr. Addison, namely, spontaneous or idiopathic anaemia, with 
melanopathia of the skin, and associated disease of the capsulae suprare- 
nales — disease of the capsulae suprarenales, irritation or disease of the 
solar plexus, arrested haematogenesis, augmented chromatogenesiS, ex- 
haustion, death. In a word, the solar plexus is the actual source of all 
these successive phenomena, and the disease of the capsulae suprarenales 
only the exciting cause. A state of irritation or disease of the solar 
plexus will explain all those symptoms which Ave have difficulty to com- 
prehend as flowing from such apparently insignificant organs as the 
suprarenal capsules. It will explain, also, how similar effects result 
from diversity in the nature of the disease of those organs; how atrophy, 
hypertrophy, induration, tubercular deposit, carcinomatous deposit, may 
all occasion the same series of symptoms ; it will explain the arrest of 
formation of the red coloring matter of the blood, and the consequent 
augmentation of the white corpuscles; and it may be a means of ex- 
plaining the hyperformatioD of pigment in the skin, and in other tissues 
of the body. And farther, it will remove an objection which I should 
otherwise be inclined to set up, namely, the diversity in the forms of 
the melanopathia, described by Dr. Addison. For, as the case at pre- 
sent stands, every black patch of discoloration of the skin becomes 
the foundation of a diagnosis of diseased suprarenal capsules, and 
prognosis of speedy death ; a line of argument which is clearly un- 
founded. Bui I cannot object, indeed, I think it worthy of our most 
attentive consideration, to the diagnosis of irritation and probable dis- 



534 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

ease of the solar plexus in these cases. I should strongly protest 
against a harmless chloasma being set down as a sign of a fatal cachexia ; 
but my experience is altogether in favor of considering it a consequence 
of irritation of the great centre of innervation of the assimilative organs. 
But Dr. Addison goes further than this, and suggests the inference 
that the suprarenal capsules are the special regulators of the black 
coloring principle of the body, for, in relation to a case in which there 
was simple extravasation of blood into one of the capsules, from 
obstruction of its vein by a malignant tubercle, he observes, "this 
case would render it probable that the excess of dark pigment, so 
characteristic of renal capsular disease, depended rather upon an inter- 
ruption to some special function than upon the nature of the organic 
change ; for, with the exception of the manifestly recent sanguineous 
effusion into its tissue, the capsule itself did not appear to have under- 
gone any considerable deterioration." With such an inference I am 
indisposed to agree, and the physiology of the suprarenal capsules in 
no way inclines to such a conclusion. 

SPILUS vel N.EVUS PIGMENTOSUS. 

Syn. Moles. Epichrosis spilus, Mason Good. Pigmentmuttermaler. 

Germ. 

Besides the patches already described, which are even with the 
surrounding skin, and in every way identical in structure, excepting 
as regards increased production of pigment, there are other discolored 
spots and patches found upon the integument, which are termed 
pigmentary noevi or moles. The subject of naevus, or mother's mark, 
does not belong to this division of cutaneous affections; but it is 
necessary here to allude to these spots, on account of their dissimi- 
larity to the rest of nsevi, which latter are vascular alterations of the 
skin (p. 510). Pigmentary nsevi, on the other hand, are not more 
vascular than the rest of the integument ; they are characterized by a 
yellowish or brownish, and sometimes a black color, 1 are very slightly 
or not at all raised above the level of the skin, and are frequently 
covered with short bristly hairs. The dark color of these patches 
evidently depends on augmentation of the pigment of the rete 
mucosum, and deposition of pigment in the papillary layer of the 
derma. Pigmentary nsevi are various in point of size, being some- 
times small, and at other times so large as to cover nearly one-half 
the face, or a considerable extent of the trunk of the body, or of one 
of the limbs. They are met with on all parts of the surface, but par- 
ticularly on the face and back. When they are raised above the level 
of the adjacent surface, the elevation depends chiefly on the presence 
of the hair follicles and their contained hairs, which give an increased 
thickness to the skin. 

Although perfectly innocuous in their nature, pigmentary nsevi 
are generally unsightly ; in such cases, the medical practitioner is 
appealed to, and it becomes necessary to adopt measures for their 

1 Spilus, ab tnriXof, macula. 



DISEASES OF THE PIGMENTARY STRUCTURE. 535 

cure. When of small size, they may be removed without incon- 
venience by means of a fine point of potassa fusa ; but when of large 
dimensions, they call for the use of the bistoury. They should be in- 
cluded within two incisions, embracing an elliptical portion of skin, 
and in the direction of its natural folds. With this precaution, all 
trace of the operation is speedily obliterated. 

II. DIMINUTION OP PIGMENT. 
LEUCOPATHIA. 

As, in the preceding section, we had occasion to reflect upon the 
production of an excess of pigment in the skin, originating in causes 
wholly unknown, so now we have to consider an opposite state as 
regards the pigment, namely, that in which there is a diminution or 
total absence of this production, leucopathia. The former state, when 
unassociated with disease, is usually accompanied by robust health 
and augmented strength in the individual, while, on the other hand, 
destitution of the natural pigment is indicative of debility of the 
nervous and vascular systems, and weakness of the physical and 
moral energies. Diminution of the natural pigment of the skin may 
be congenital or accidental, and in distribution it may be general or 
partial. 

GENERAL LEUCOPATHIA; ALPHOSIS. 

Achroma, Alibert. SJpiehrosis alphosis, Mason Good. Albino skin. 

Albinoes are met with among all races of mankind, among the 
dark-complexioned nations of the south, as well as among the fair- 
haired inhabitants of the coldest regions of the earth. They are re- 
markable for a congenital and entire absence of pigment, not only in 
the rete mucosum of the skin, but also in those other parts of the 
body which are usually characterized by their dark color. The skin 
in these persons is of a milk-white color, the hair is fair, and usually 
soft and silky ; sometimes it is harsh and wiry in texture, and the 
entire body is covered with a soft white down. The eyes are red, 
from the absence of pigment in the choroid membrane, and the iris 
presents a pinkish tint. 1 There is intolerance of light, the pupil is 
small, from the contraction of the iris to exclude the luminous rays, 
and the person bows his head habitually towards the ground, in 
order to shadow the retinae as much as possible. At dusk, however, 
when the luminous rays are fewer in number, the albino rears his 
brow, and walks erect, his eyes are no longer overwhelmed by excess 
of li,'_ f lit, and he is enabled to see surrounding objects in the night of 
other men. The albino is usually short of stature, and weakly in 
powers both of body and mind. 

Albinism is sometimes accidental in its development, arising without 
any apparent cause, upon some part of the body, and thence extending 

1 In India "the irides are blue and the hair is silvery white.'" — Brett on the Surgical 
Diseases of India. 1840. 



536 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

to the entire surface. Instances of accidental general leucopathia have 
only been observed among the natives of Africa. 

An example of complete albinism in the negro, alpliosis cethiopica; 
leuccethiopes, might have been seen frequently in the streets of London, 
a few years back ; the subject was a tall, sickly-looking man, who 
styled himself Henry Alexander Commotius Stewart, the African 
Albino. This man was born in New Providence, of black parents, 
his father being a negro from Guinea, and his mother a native of the 
Island of Antigua, descended from African slaves. His four brothers 
and sisters were all black. He is tall, has a complexion like that of a 
dead leaf, sprinkled over with large and irregular freckles, light-colored 
eyes, and a light red woolly hair, surmounting features obviously bear- 
ing the African stamp. 

PARTIAL LEUCOPATHIA. 

Eplielis alba. Epichrosis pcecilia, Mason Good. Cutis variegata. 
Piebald skin. 

Partial leucopathia, or the diminution or absence of pigmentary 
secretion upon one or more parts of the body, as a congenital peculiar- 
ity, is most frequently observed araong the darker races of mankind, 
in whom it is likely to attract most attention ; it also occurs, but more 
rarely, among the white races. Several instances of the " pied negro" 
have been recorded, and such defects of development are not very 
uncommon among the African race. When the patches are seated on 
the scalp, the hair participates in the change, and is produced of 
snowy whiteness. 

Partial leucopathia is sometimes accidental in its development, 
occurring without apparent cause as one of the natural changes of the 
system. A remarkable case of this kind, the subject being a native 
of Virginia, is recorded in the fifty-first volume of the Philosophical 
Transactions. 

In my Portraits of Diseases of the Skin 1 is represented the appear- 
ance of the skin in a gentleman, who, originally of fair complexion, 
became brown (melanopathia), and subsequently lost the cutaneous 
pigment on various parts of the body (leucopathia). Several white 
patches made their appearance on his face; one nipple was perfectly 
divested of pigment, while the other was as dark as that of a woman 
far advanced in pregnancy ; and, as if to render the case still more 
remarkable, the lost pigment was accumulated on the side of the 
trunk in blotches of deep black. He had been undergoing this 
change for seven years before he came under my observation. 

In Europeans, this alteration is most frequently met with on the 
scrotum of old persons, in which situation it appears under the form 
of irregular patches, and sometimes of longitudinal stripes. M. Guyon 
observed partial leucopathia in Algiers, where it is apt to take place 
in Europeans as well as in Arabs. Mr. Brett remarks that in India, 
partial leucopathia " occurs in circumscribed patches, which are quite 

1 Plate XXXIII., H. 



DISEASES OF THE PIGMENTARY STRUCTURE. 537 

insensible, though the disease commences by itching, pain, redness, 
and other marks of inflammation." These latter are probably patches 
of morphoea alba, and appertain to elephantiasis. 

Treatment. — In a case of partial leucopathia which came under 
my observation, in a young lady, whose health was in other respects 
very considerably deranged, the natural hue of the skin was entirely 
restored by means of tonics and the shower-bath, and by the applica- 
tion of stimulating liniments "to the faded spots. Mr. Brett, in his 
Essay on the Surgical Diseases of India, where this disorder is com- 
mon, observes: "The treatment consists in the exhibition of the ascle- 
pias gigantea in combination with alterative doses of mercury and 
antimony, and topical stimulants. A blister applied to the white patch 
will be found advantageous. Stimulating the affected part with sul- 
phureous douches, and with sulphur ointment and volatile liniments, 
is also of great advantage. The disease is considered by the natives 
as incurable." 



III. MORBID ALTERATION OF PIGMENT. 

The affections which may be arranged under this designation are 
four in number, namely, 

Ephelis, t Chloasma, 

Lentigo, Melasma. 

EPHELIS. 

Syn. Sun-burn. Epichrosis ephelis, Mason Good. Macules, fuscce. 

The term ephelis (&rt ^«o<?, the sun) is intended to express the change 
which is produced on the skin of many persons by exposure to the in- 
fluence of the sun's rays. This discoloration is developed in small 
patches of irregular form, and of a variable tint of brown, upon those 
parts of the body, as the face, neck, shoulders, hands, &c, which are 
unprotected by dress. The spots of ephelis are most remarkable in 
children and women, and in persons possessing a thin and delicate 
skin. They disappear during the winter season. 

Peter and Joseph Franck indicate a difference of appearance in the 
spots by the terms ephelis umbrosa and ephelis lentigo, the former re- 
ferring to irregular brown patches, and the latter to circular yellow 
spots, somewhat resembling those of lentigo. Rayer introduces the 
mottled appearance seen upon the legs and thighs of women who sit 
over a charcoal brazier as a third variety, under the name of ephelis 
ignealis. 

Treatment. — The treatment for sun-burn is the application of a 
liniment composed of equal parts of white of egg and olive oil; to 
which, if the heat of surface be considerable, may be added liquor 
plumbi, in the proportion of twenty minims to the ounce ; an emulsion 
of bitter almonds with spirits of wine, or the benzoated ointment of 
oxide of zinc beaten into a cream with orange-flower water or elder- 
flower water. In the chronic stains called ephelis umbrosa, a lotion 
of the bichloride of mercury or nitro-muriatic acid will be found 
useful. 



538 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 



Syn. Freckles. Epichrosis lenticula, Mason Good. Sommersprossen, 
Germ. Phacia, Gr. 

Lentigo has received its name from the lentil-shaped spots which 
characterize the affection; in popular language they are called freckles. 
Freckles are small, round, yellow, or greenish-yellow spots of various 
size, but rarely larger than the diameter of a split pea. They are 
seated in the rete mucosum, and most abundantly distributed upon 
those parts of the body which are exposed to the influence of the 
light, as the face, neck, hands, &c. On these parts they are sometimes 
assembled in thick clusters, forming unsightly patches of considerable 
size. They are also met with on those regions of the body which are 
usually protected by the dress ; and are evidently dependent on some 
morbid action of the skin. 

Lentigo is sometimes a congenital affection, appearing soon after 
birth, and continuing through life, or subsiding and disappearing at 
the age of puberty. Sometimes the spots vanish at other periods, and 
without appreciable cause. They are almost peculiar to persons of 
light complexion and hair, and are especially frequent in those whose 
hair is red. # 

The diagnosis between lentigo and ephelis is the permanence of the 
former, its independence of season, and its accustomed seat in the skin 
of persons of light complexion. Ephelis, on the other hand, commonly 
disappears during the winter, is excited by the sun's rays, and occurs 
in persons of all complexions. 

Treatment. — The treatment of lentigo consists in the application 
of some moderately stimulating therapeutic remedy which may excite 
the skin to a more healthy function. The lotion of bitter almonds 
containing from five to fifteen grains of the bichloride of mercury to 
the half pint, is well adapted for this purpose. I have seen the lini- 
ment of lime-water and oil, with a small quantity of liquor ammonige, 
of use in this unsightly affection; a lotion of the bichloride of mercury 
with elder-flower water is also sometimes useful ; or a lotion of borax 
and rose-water. Plenck recommends acetum armoracise; pasta amyg- 
dalarum amarum ; fel taurinum ; lac sulphuris ; aqua phagasdenica 
(yellow wash) ; and solution of sulphate of zinc. Fel taurinum is a 
favorite cosmetic remedy among the older physicians. 

CHLOASMA. 

Syn. Pityriasis versicolor, Willan. Maculae hepaticce. Ephelis hepa- 
tic a. Hepatizon. Leberjlecke, Germ. 

Chloasma 1 is characterized by the development of one or more 
patches, of irregular form and size, and of a pale or saffron yellow, or 
brownish yellow color, upon any part of the surface of the body, 
particularly on the face, neck, and trunk. The seat of discoloration 

1 Vide, Portraits of Diseases of the Skin, Plate XXXV., A. 



DISEASES OF THE PIGMENTARY STRUCTURE. 539 

is the rete mucosum; it is accompanied by a slight degree of local 
irritation, and lasts from a few days to several months or years. 

Chloasma first makes its appearance in the form of small spots, of 
a dull, reddish color, which increase in size, and present a yellow 
tint, approaching more or less to a saffron, or brownish yellow hue, 
or dead-leaflike tint. These spots are at first distributed irregularly 
upon the cutaneous surface, they then enlarge and communicate with 
each other, so as to form patches of considerable extent. Indeed, the 
patches are sometimes so extensive that they may be mistaken for the 
sound skin, while the intervening parts of the natural hue may be re- 
garded as the discolored integument. They are frequently developed 
without accompanying symptoms ; at other times, they are attended 
with considerable itching, which continues throughout their course, 
and gives rise to great annoyance. The pruritus is increased by 
mental emotion, by impending catamenia, by stimulating food or 
drink, and by the warmth of bed, and is often exasperated at the latter 
period to such a degree as to deprive the sufferer of sleep. When the 
disease subsides, desquamation of the epidermis ensues, and is repeated 
several times after the total decline of the symptoms. 

The symptoms above detailed apply to chloasma when recent and 
in an active state ; when chronic, it gives rise to very little inconve- 
nience. Its location on the skin offers some little variety. In women, 
I have generally observed it on the front of the chest, on the abdo- 
men, pit of the stomach, groins, and bends of the arms ; in men, it 
seems most frequently to occupy the abdomen, running upwards 
along the sides of the trunk to the armpits and back of the neck, and 
downwards into the groins and inner parts of the thighs : it is also 
commonly seen around the neck, becoming blended above with the 
deeper color of the face. In one gentleman, it affects also the bends 
of the elbows ; and, in another, is situated only on the back, extend- 
ing downwards on the trunk to the waist. On examination with the 
lens, there is a conspicuous alteration and elevation of the skin, and a 
mealy and pulverulent desquamation resulting from the fact of the 
hyperpigmentous cells being more friable and less adapted to assume 
the condensed character than the scales of healthy epidermis. 

Diagnosis. — There is little danger of mistaking chloasma for any 
other cutaneous affection ; its yellow color, the troublesome pruritus, 
and the mealy epidermal exfoliation, are its characteristic signs. In 
pityriasis there is a more altered and rougher state of the skin, a 
greater degree of redness, a mixture of soreness with pruritus after 
scratching, and larger scales. 

Causes. — Chloasma may occur at all ages, and in both sexes, but 
is most frequent in women, and particularly in those who possess a 
fair and delicate Bkin. The usual cause of the affection in females is 
uterine irritation, induced by impending catamenia, amenorrhoea, 
(maculae amenorrhocicae), pregnancy (maculae gravidarum), &c. It is 
by no means uncommon to observe chloasma a short time previously 
to the appearance of the catamenia, but the disease ceases as soon 
as the latter are established. In like manner the affection some- 
times lasts through a considerable period of pregnancy, invading at 



540 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

its commencement and terminating in its course ; or commencing at 
a later period, and ceasing after the completion of parturition. 
Other exciting causes of chloasma are, gastro-intestinal irritation, 
stimulating food and drinks, hepatic irritation ; irritations, in fact, 
which are due to a morbidly sensitive state of the solar plexus of 
nerves. 

Dr. Gustav Simon places chloasma in his sixth group of diseases of 
the skin, which he entitles Parasites; considering this eruption as 
depending, like favus, sycosis, and alopecia circumscripta, on the 
presence of a parasitical vegetable fungus. I do not agree with him 
in this opinion ; and have failed to discover any vegetable organisms, 
although I have searched for them with care; and have seen what has 
been mistaken for them. 

Treatment. — Chloasma gives way without much difficulty to the 
nitro-muriatic acid with gentian, conjoined with a mild aperient ; and 
the local application of a lotion of the bichloride of mercury in emul- 
sion of bitter almonds, two grains to the ounce. Indeed, it seems to 
yield to almost any stimulant, such as the nitro-muriatic acid lotion, 
the nitric oxide of mercury ointment, or sulphur ointment. But it is 
apt to return, and constitutional remedies are necessary to alter and 
improve the functions, upon whose failure of proper action this affec- 
tion depends. I have seen it get well under small doses of the bichlo- 
ride of mercury ; and have sometimes found it necessary to have 
recourse to Donovan's solution, or one of the arsenical preparations. 
It is perfectly curable. 

MELASMA. 

Syn. Pityriasis nigra, Willan. Der Schwarze Flecke. 

Melasma is an alteration of the chromatogenous function of the 
skin analogous to chloasma, and differing from the latter only in 
the darker color of the abnormal pigment. Melasma is a rare 
disease, and has been chiefly observed in persons of weakly consti- 
tution. It makes its appearance in the form of blackish patches, of 
irregular size, upon one or several parts of the body. The affected 
skin is dry and granular to the touch, and the epidermis cracks and 
desquamates in furfuraceous scales. On the fall of the morbid 
epidermis, the newly-formed membrane usually presents the normal 
tint. 

Willan observed this affection in children born in India, and 
brought to this country, and regarded it as a variety of pityriasis ; 
pityriasis nigra. In Willan's cases the disorder " commenced in a 
partially papulatcd state of the skin, and terminated in a black disco- 
loration, with slight furfuraceous exfoliations. It sometimes affected 
half a limb, as the arm or leg, sometimes the fingers and toes." 
Alibert describes and delineates it as a discoloration of the skin, 
under the name of " ephelide scorbutique ;" and Rayer assigns to it 
the title under which it is considered in this place. The latter 
author remarks on its frequent occurrence in association with pellagra, 



DISEASES OF THE PIGMENTARY STRUCTURE. 541 

and observes, that it " appeared among a certain number of indivi- 
duals of both sexes, and of all ages, in the epidemic of Paris in 
1828." 

The same characters which distinguish chloasma from pityriasis form 
the principal diagnostic characters of this disease ; substituting the 
yellow tint of the former for the black of melasma. 

Treatment. — The indications for treatment are the same as in 
chloasma. 

IV. CHEMICAL COLORATION OF THE DERMA. 

DECOLORATIO argentea. 

Persons who have taken nitrate of silver for a certain length of 
time are liable to be affected with alteration of color of the skin. In 
the first instance, this alteration consists in the suffusion of the surface 
with a bluish tint, which subsequently becomes of a greenish slate color. 
The discoloration takes place upon all parts of the surface of the 
body at the same time, but is most remarkable in those regions which 
are exposed habitually to the influence of light, as the face and hands ; 
and, in the latter situations, it not unfrequently assumes a more or 
less deep black. The color is curiously modified in certain localities 
by admixture with red ; hence, in the conjunctiva, and on the lips, it 
presents a livid brown tint, and on the general surface it is much 
deepened by those causes which, under other circumstances, would 
produce pallor ; for the same reason the discoloration is more apparent 
upon persons naturally pale than in those who possess a fresh com- 
plexion. 

Once established, the discoloration produced by nitrate of silver 
lasts for the entire life of the individual, without alteration. In some 
few instances only, it has been observed to diminish slightly in the 
course of years. 

Treatment. — Few persons afflicted with this deformity would feel 
disposed to endure it calmly, without making some attempt at its re- 
moval ; hence, it becomes necessary to inquire what remedies might 
be employed with the best chance of a successful result. The iodide 
of potassium has been proposed for this purpose ; and, as in moderate 
doses it is a safe remedy, it deserves a trial, and may be continued for 
a length of time. Its known powers of removing nitrate of silver 
stains from the surface of the skin, are suggestive also of its use as a 
local application. For the same reason a lotion of the bichloride of 
mercury, with or without the hydrochlorate of ammonia, is a judicious 
remedy. 



542 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 



CHAPTER XX. 



DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN. 
DISEASES OF THE SUDORIPAROUS ORGANS. 

Our knowledge of the existence and nature of the sudoriparous 
system is comparatively recent. It was first made known by the 
researches of Purkinje, Breschet, and Roussel de Vauzeme, and their 
discovery has thrown much light on the pathology of the sudoriparous 
organs. It had long been observed by dermatologists, that the per- 
spiratory secretions may become morbidly augmented without fever, 
and without apparent visceral disease, a disorder which has been 
termed ephidrosis. The sweating sickness which prevailed in England 
during the sixteenth century, and which still continues to make its ap- 
pearance from time to time in France, receives much elucidation from 
our knowledge of the anatomy and physiology of the sudoriparous 
organs. The observation of this function will probably discover to us 
also certain morbid phenomena, which may be referred to deficiency 
of perspiratory secretion, and numerous instances are recorded of al- 
teration in the physical properties of the secretion. So that the dis- 
eases of the sudoriparous system may be referred to the three heads 
which are generally applicable to secreting organs, namely, 

Augmentation of secretion, 
Diminution of secretion, 
Alteration of secretion. 

I. AUGMENTATION OF SECRETION. 
IDROSIS. 

Ephidrosis p>rofusa, Mason Good. Hyperidrosis, Swediaur. 

Idrosis 1 is an excited action of the sudoriparous glands, attended 
with symptoms which indicate inflammatory determination. It is cha- 
racterized by excessive perspiration, the perspiratory secretion being 
altered in its qualities ; by more or less redness of the skin ; by heat 
and tingling or itching ; and by shooting and lancinating pains. 
When the disease is general and acute, it is attended with febrile 
symptoms, and often with the development of serous vesicles, or suda- 
mina (page 208). 

Idrosis presents two principal varieties, namely, 

Idrosis simplex, Idrosis maligna. 

1 Der. iVfu.;, sudor. 



DISEASES OF THE SUDORIPAROUS ORGANS. 543 



IDROSIS SIMPLEX. 

Syn. Ephidrosis. Sudatoria simplex. Sudatoria miliaris. Miliaria. 
Miliaria rubra. Miliaria alba. 

Simple idrosis is a subacute affection, sometimes general, but more 
frequently partial in its attack. When general, it is apt to be accom- 
panied, after the lapse of three or four days, with sudamina, consti- 
tuting that form of the disorder termed sudatoria miliaris. These 
vesicles first make their appearance on the neck, then on the trunk 
and abdomen, and then on the skin of the armpits, and inner sides 
of the thighs. The disorder is accompanied by febrile symptoms, 
and torpor of the alimentary canal, and its sudden arrest is sometimes 
followed by visceral congestion. Subacute idrosis usually terminates 
in a week or a fortnight. 

During the excessively hot weather which occurred in the early 
part of August, 1856, I had occasion to treat several cases of idrosis. 
The symptoms were these : after taking food, and sometimes without 
the stimulus of food, as during the night, the patient was suddenly 
seized with a feeling of faintness and oppression at the epigastrium ; 
a profuse cold perspiration immediately bedewed the whole surface 
of the skin, and continued for a space of time, varying between a 
quarter and half an hour. In some instances these symptoms were 
repeated at every meal, in others only once in the day, at dinner or 
supper, and gave rise to considerable exhaustion and debility. I saw 
about ten cases, and one was followed by vomiting and slight fever. 
I prescribed quinine with sulphuric acid, and cooler weather setting 
in, the patients soon got well. 

Chronic idrosis is less apt to give rise to constitutional symptoms, 
and to the production of miliary vesicles. " M. Dupont has published 
an account of a curious case of a chronic general ephidrosis which 
lasted upwards of six years. The woman who was thus affected became 
pregnant during this time, and was happily delivered of an infant, 
which she nursed herself. This ephidrosis, which, according to him, 
was independent of any other affection, after having been fruitlessly 
combated by various remedies, yielded at last to extract of aconite, 
given at first in doses of half a grain, and gradually raised till sixteen 
grains a day were taken." 1 " Hoffman makes mention of a very old 
man, subject to continual perspiration, so that his whole nourishment 
passed through the pores." And Willis notices the case of a lady 
"whose perspirations were so prodigious," that basins were set 
beneath her " to receive the trickling humor." 

Partial idrosis (ephidrosis partialis) is more common than the 
general form ; sometimes it is confined to the feet or hands alone, at 
other times to the axillne, perineum, or scalp, and " Ilartmann cites 
the singular fact of a woman who, during pregnancy, perspired only 
on the right side of her body." 2 I have, at present, under treatment, 

1 Rayer, Translation, page 920. The extract of aconite here referred to is much 
inferior in strength to the English alcoholic extract, of which the dose is ^ to £ a 
grain. 2 Rayer, loc. cit. 



544 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

a young lady, whose hands are the seat of this disagreeable affection ; 
under the influence of a slight nervous excitement, the hollow of the 
palms fills with secretion, and the perspiratory fluid drips from her fin- 
gers as she stretches them out. A gentleman whom I attended lately 
for severe gastric disorder, called on me one morning, with rills of per- 
spiration running down one side of his forehead and face, the opposite 
side being perfectly dry ; and an eminent actor told me the following 
anecdote of himself: When a young man, starring in America, he 
had one night, in the summer time, been playing in a tragedy, in which 
he was violently heated, and had scarcely time to cool, when he was 
obliged to come on the stage again as Sir Archy MacSarcasm, in 
Macklin's comedy of Love a la Mode. The make-up for this character 
required that he should convert his features, by means of paint, into 
those of an old man. In the course of the play he was struck by 
perceiving himself " the cynosure of neighboring eyes," particularly 
those in the front rows of the pit, and concluding that it must be the 
excellence of his acting which was attracting so much attention, felt 
highly flattered, and exerted himself to the utmost. From time to 
time, however, he was startled at the bursts of laughter and applause 
falling in the wrong places, and was thoroughly puzzled at the 
unusual sensation he was creating. On retiring to his dressing-room, 
after making his best and most grateful bow to an hilarious audience, 
the mystery was explained ; it was not his brilliant acting alone which 
had brought down such noisy honors on his head, but the drollery of 
his face, one-half of which was washed clean of its wrinkles by 
partial perspiration, and displayed the juvenile features of twenty ; 
while the other half exhibited the careworn lines and withered 
seams of eighty. In his case, while one-half the face was affected in 
this peculiar manner, and the other half was dry, his chest was acted 
on in a precisely opposite way, the perspiratory side being reversed. 
At a later period of his life the perspiratory action ceased over the 
entire body, and, as a consequence, he suffered bitterly in his health. 

The perspiration in idrosis is acid, disagreeable in odor, and so pro- 
fuse as to produce softening and opacity of the epidermis, which, on 
the soles of the feet, is often corrugated, like that of washerwomen. 
The disease is most commonly met with in the summer season, occur- 
ring during extreme heat, excessive exercise, &c. 

IDROSIS MALIGNA. 

Sudatoria Maligna. 

The malignant form of idrosis appears to correspond with the 
sweating sickness of the sixteenth century, a disorder which is no 
longer met with in England, but which would seem by the numerous 
reports made to the Acade'urie de Medecine, to be still prevalent in 
France. The disease is infectious and contagious, and occurs epide- 
mically. The following brief notice of the disorder is an abstract of 
the description given by Rayer. 

Malignant idrosis is commonly associated with inflammation of the 
stomach and intestines ; inflammation of the lungs ; inflammation of 



DISEASES OF THE SUDORIPAROUS ORGANS. 545 

the bladder; or inflammation of the cerebro-spinal axis. When the 
digestive organs are especially affected, the disease is characterized 
from the commencement, or at an early period, by a severe constric- 
tion at the epigastrium, spasm of the diaphragm affecting respiration, 
distressing anxiety, deeply drawn sighs, feeling of weight in the chest, 
with a sense and alarm of suffocation, and, in some cases, vertigo, 
violent headache, and nausea. When the lungs are the seat of inflam- 
mation, there is a deeply-seated pain in the chest, crepitating rattle 
in the bronchi, oppressed breathing, frequent full pulse, and sangui- 
nolent expectoration. When the bladder is inflamed, there are pains 
in the hypogastrium, difficulty in passing the urine, with high color 
and deficiency of that secretion. And when inflammation of the 
cerebro-spinal axis is present, there is headache, flushed countenance, 
full, starting eyeballs, throbbing temples, contracted or fixed pupil, 
coma, and convulsions. 

These symptoms occasionally prove fatal in twenty-four or forty- 
eight hours, or the disease may run on for two or three weeks. 

The following cases of idrosis were observed by M. Marrotte, in 
the Hotel Dieu, at Paris, at the close of an epidemic of typhus fever, 
which raged in that city in 1842. M. Honore, in whose ward the 
patients lay, had never before seen cases of this disease; and M. 
Rayer, who is well acquainted with the disorder, had never seen it in 
Paris. 

A young man, twenty-three years of age, was received into the 
hospital July 29, complaining of pain in his head, lassitude, great 
prostration, thirst, and drowsiness. His skin was hot, pulse frequent, 
tongue and teeth foul ; had had no action of bowels, which could only 
be brought to move by medicine; no rumbling in the iliac fossae. 
There were none of the lenticular spots which accompanied the pre- 
vailing epidemic. The skin, though very hot, was neither dry nor 
burning ; on the contrary, it was moist. He complained, moreover, 
of an uneasy sensation and feeling of anxiety at the pit of the stomach, 
which led to the administration of an aperient emetic. 

The present symptoms have lasted three days. His first indications 
of disease were, general uneasiness and loss of appetite, but not suffi- 
ciently pressing to induce him to relinquish his duties. Suddenly, in 
the middle of the day, he was seized with pain in the head and great 
prostration, which forced him to take to his bed; but he had no rigors, 
no diarrhoea; his skin was at the same time covered with a moderate, 
though constant, perspiration. 

For two or three days after admission the patient continued in the 
state above described, without having been benefited by a bleeding 
from the arm, practised previously to his application at the hospital. 
After this period the disease assumed all its severity, the prostration 
and drowsiness were more marked, the perspirations and oppression 
became more intense. The perspiration streamed forth continually 
from the skin, the heat of skin increased, the pulse became stronger, 
and more frequent; the oppression was accompanied by cough and 
mucous expectoration; and auscultation discovered mucous crepitation 
throughout the whole extent of the bronchi. 

35 

l 



546 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

This combination of symptoms persisted in all their force for ten or 
twelve days ; at the expiration of that period the patient felt improved. 
His amendment seemed in some degree to have been effected by a 
change in the position of his bed to a better ventilated situation. Un- 
der the influence of this change of position, the perspirations dimin- 
ished, the tongue became soft, moist, and simply furred, the teeth be- 
came clean, and the thirst was diminished. 

On the 25th of August the patient is progressing; the surface is 
still moist in situations where the skin is naturally perspirable. Vesi- 
cles are dispersed about the neck and trunk, some being filled with a 
milky serum, and surrounded by a slight areola; others being trans- 
parent. The return of appetite is more tardy. 

A second case was that of a man, upwards of six feet in height, 
thirty years of age, who had felt, every evening, a sensation of fever- 
ishness, for about twelve days; his appetite failed; he suffered from 
thirst; his skin felt burning hot, and he experienced considerable 
drowsiness. Since his admission, the fever has become increased and 
continued; his skin is covered with a constant perspiration; he has 
headache, pain in the left side, anxiety, and oppression at the prae- 
cordia. • 

In the course of five or six days, the anxiety and oppression have 
assumed an excessive degree of intensity ; he has cough and expecto- 
ration, and mucous rales are very obvious throughout the whole of 
his chest. The perspirations have increased, together with the heat 
of skin, and the hardness and frequency of the pulse. The abdomen 
is distended, the tongue thickly furred; there is great prostration and 
perpetual drowsiness. An eruption of red pimples appeared upon 
the neck, and spread thence to the face and trunk ; in two or three 
days these pimples were surmounted by vesicles, containing a lactescent 
fluid, and were followed by successive eruptions of sudamina, chiefly 
of the phlyctenoid kind, which occupied the vacant spaces between the 
papulae. 

As the eruption increased, and advanced in development, the 
oppression decreased, the pulse became softer, and the abdomen 
diminished in bulk. In this patient, as in the former, the bowels 
were inactive, and required the aid of medicine. His intellectual 
powers were unaffected, and the appetite returned gradually to its 
normal standard during recovery. On the 25th of August he was 
convalescent. 

In a third case, the patient was a young man, twenty-four years of 
age; he had for some time suffered from uneasiness, loss of appetite, 
and lassitude, for which symptoms he was bled from the arm without 
benefit. He was next seized with headache, vomiting, diarrhoea, and 
perspirations, and was forced to take to his bed, where he remained for 
eight days, suffering with perspirations during the whole period. 

On admission, August 16th, he was in a state of extreme prostra- 
tion; heaviness was exhibited in his features, his tongue and teeth 
were covered with sordes, the perspirations were general and contin- 
ual ; his abdomen was distended, and he suffered from thirst. For 
several days he remained in this state, answering with difficulty the 



DISEASES OF THE SUDORIPAROUS ORGANS. 547 

questions that were put to him. He had retention of urine, and a 
full basin of clear urine was withdrawn by the catheter. In seven or 
eight days from this time, his state was improved; the stupor has 
diminished, and the tongue is moist. The perspirations are mitigated, 
and this mitigation became strikingly apparent as soon as the patient 
was removed to a better ventilated situation. They have not yet, 
however, wholly ceased ; the hardness and frequency of the pulse 
have yielded. 

From this period, amelioration was as speedy as in the former cases, . 
but the return of appetite was not so marked as is customary after 
typhus fever ; he was not so much emaciated as are patients conva- 
lescent from the latter disease, but he appears more debilitated. 

M. Marrotte remarks with regard to these cases, on the exacer- 
bation which took place at the close of the fifth or sixth day ; the con- 
tinuous perspirations which existed at that period both day and night ; 
the intensity of the prostration and drowsiness ; the cutaneous 
eruption which at this period made its appearance, but without being 
critical ; the oppression and anxiety at the prsecordia appearing with 
the perspirations ; the protraction of amendment to the term of two 
weeks from invasion ; the continuance of perspirations to the close 
of the third week, and the marked benefit resulting from better air 
and ventilation ; all of which symptoms he looks upon as patho- 
gnomonic. 

Contrasting the disease with typhus fever, he recalls the negative 
characters of sudatoria. There was no diarrhoea in the commence- 
ment ; there were no headache, rigors, or vomitings ; the prostration 
of the physical powers is rarely so great ; it is rare that the tongue 
and teeth are so speedily covered with sordes, or that drowsiness is so 
strongly marked. The first week passed away without epistaxis, and 
without lenticular spots. The pulse of sudatoria, again, has never 
the smallness and frequency of the pulse of typhus. 

Treatment. — The indications for treatment in idrosis are, to re- 
store the secretions, to allay the irritation of the inflamed perspiratory 
organs, to restore tone, and to engage with local congestions as they 
arise. The first of these indications is effected by means of abstinence, 
diluents, and the ordinary antiphlogistic remedies. The second calls 
for the use of the tepid bath. The third is met by quinine, salicine, 
and the mineral acids. The fourth may require general or local 
bleeding, blisters, mustard plasters, mustard foot-baths, &c. ; these 
remedies being employed according to the seat, and in proportion to 
everity of the symptoms. The suggestion of M. Dupont, relative 
to the extract of aconite, is worthy of recollection. A sulphureous 
bath is recommended by Rayer; and, in chronic cases, sulphureous 
vapor might be found useful. 

After regulating the secretions, tannin will be found a valuable 
remedy in these cases. I have employed tannin in idrosis of the 
feet, witli considerable advantage, conjoining with it chloride of lime, 
as a lotion for local application. A strong solution of alum is also 
serviceable, as is also a spirituous solution of the juniper tar ; and I 
once saw a gentleman who informed me that he had relieved himself 



548 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

of this discomfort by the use of a brine foot-bath every night. Pana- 
rolus, remarking that perspiration of the feet doth very much torment 
people, continues, " for "which I can tell them a speedy remedy ; 
namely, if they put some powder of myrtle into their linen socks ; 
but let them have a care they fall not into worse diseases by the cure 
of this, as I have often seen ; for this excretion preserves from many 
diseases, and should rather be promoted than any ways checked." 

II. DIMINUTION OF SECRETION. 
ANLDROSIS. 

Diminution of perspiratory secretion from arrest of function of the 
sudoriparous glands has hitherto been observed only in relation with 
febrile diseases. It is probable, however, that the perspiratory secre- 
tion, like that of other secerning glands, may be diminished and 
checked as a consequence of inflammatory disorder of the sudoriparous 
glands, independently of the rest of the organism. The dryness of 
skin which we occasionally meet with in some individuals bears no 
reference to the sudoriparous system, but is dependent on the absence 
of secretion of the sebiparous glands. In the Philosophical Transac- 
tions 1 is recorded the case of a " gentleman near Leyden, who, being 
much addicted to the study of astronomy, and spending very many 
nights in star-gazing, had, by the nocturnal wet and cold temper of 
the air, in such manner obstructed the pores of his skin, that little or 
nothing exhaled from his body ; which appeared hence, because that 
the shirt he had worn five or six weeks was then as white as if he had 
worn the same but one day." 

III. ALTERATION OF SECRETION. 

OSMIDROSIS. 

Ephidrosis olens, Mason Good. 

Alteration in the physical properties and chemical composition of 
perspiration is coexistent with augmentation of secretion, and may 
also occur independently of increase in quantity. The most apparent 
alteration in physical properties is that which relates to odor, osmi- 
drosis. 2 The perspiration frequently assumes an acid smell, probably 
from containing a larger proportion than usual of acetic acid, or a 
rancid odor from excess of butyric acid, or a combination of both, con- 
stituting a fetid and disagreeable odor, which has been aptly com- 
pared by Rayer to the smell of "rotten straw." The same author 
remarks, " I had a woman under my care in the Hopital de la Charite", 
affected with chronic peritonitis, and who, some time before her death, 
exhaled a very decided odor of musk : the pupil who called my atten- 
tion to this circumstance had observed the smell for several days while 
iressing a blister, but thought it owing to a bag of musk put pur- 

1 Abridgment, vol. iii. 2 Der. o<rf*fo odor. 



DISEASES OF THE SUDORIPAROUS ORGANS. 549 

posely into the bed to overpower other had smells. 1 The woman, how- 
ever, assured us that she had no description of perfume about her, and 
I satisfied myself that her linen, which was frequently changed, was 
not impregnated with any perfume before being delivered to her from 
the laundry of the hospital. The odor of musk, the existence of which 
was fully ascertained by myself and several physicians, and which was 
very perceptible on the arms and other regions of the body, did not 
become more powerful from rubbing. After continuing for about eight 
days the smell became fainter, and nearly vanished the evening before 
the patient's death." Speranza 2 relates a similar case. Schmidt has 
inserted in the Ephemerides Naturae. Curiosorum the account of a 
journeyman saddler, three and twenty years of age, of rather robust 
constitution, whose hands exhaled a smell of sulphur so powerful and 
penetrating as very soon to infect any room in which he happened to 
be. I was once consulted by a valet de chambre, who could never keep 
a place in consequence of the unpleasant odor he left behind him in 
the rooms which he had been occupied in cleaning. There have been 
instances of individuals who, to obtain their discharge, or immunity 
from military service, have simulated these offensive perspirations, by 
rubbing their axillae with the animal oil of dippel, assafoetida, a piece 
of much-decayed cheese, putrid fish, &c. 

Another author observes, "the sweat of persons with the itch is 
said to have a mouldy odor, while that of syphilitic patients is said to 
smell sweet. The sweat of rheumatic and gouty persons has an acid 
smell, while in putrid fever and scurvy it has a putrid odor ; in jaun- 
dice it is said to resemble musk in its smell. In Stark's General Pa- 
thology we find it stated, that the .odor of the sweat in scrofula resem- 
bles that of sour beer, while in intermittent fever it smells like fresh- 
baked brown bread." " Anselmino found free acetic acid in the sweat 
of women during their confinement; and, according to Stark, the quan- 
tity of free lactic acid is increased in the sweat during scrofula, rachitis, 
and certain cutaneous eruptions." " Anselmino found a larger propor- 
tion of ammonia in the sweat after an attack of gout than in any other 
case. Behrend states that the sweat in putrid and typhus fever is 
ammoniacal, and in nervous diseases, according to Nanche, it becomes 
alkaline. All sweat with a putrid odor probably contains free ammonia. 

1 Mason Good observes, that the odor of musk, although not often thrown forth from 
tin- human body, "is, perhaps, the most common of all odors that escape from the skin 
of other animals. We discover it in many of the ape kind, and especially in the simia 
jin rlnis : still more profusely in tbc opossum, and occasionally in hedgehogs, hares, serpents, 
and crocodiles. The odor of civet is the production of the civet-cat alone, the viverra 
zibelha, and viverra civetta of Linnu:us, though we meet with faint traces of it in some 
varieties of die domestic cat. Among insects, however, such odors are considerably more 
common, and by far the greater number of them are of an agreeable kind, and of very 
high excellence; Ibr the musk scent of the rerainlii.r. iiiosiluilits, the apis fragrans, and the 
tipula nwscliifcrn, i-. much inure delicate than that of the musk quadrupeds; while the 
i irii minx suaveoli w.s, and Beveral species of the ichneumon, yield the sweetest perfume of the 
rose; and the peliolated tphex, a balsam ether highly fragrant, but peculiar to itself.'* Vol. 
v. p 55 i . Second edition. 

2 Observation d'odeur aromatique exhalee par la peau de l'avant-bras. Archives Gene- 
rales de Medecine. Vol. xxx. p. 399. 



550 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

In cases of gouty and urinary concretions, the quantity of phosphate 
of lime appears to be increased." 1 

Dr. Piutti, of Elgersburg, has made some analyses of morbid sweat, 
the leading feature of which is the absence of the salts of lime. Simon 
thinks that the phosphate of lime appertains to the epidermis, while 
Berzelius, more correctly, in my opinion, believes it to be a constituent 
part of the secretion, and held in solution by a free acid. Piutti omits 
all notice, likewise, of sulphuric acid and potash. The three analyses 
made by Piutti are as follows : 



1. 


2. 


3. 


995.5 .. 


. 993.0 


. . 994.6 


3.0 .. 


4.0 


3.3 


.5 .. 


.8 


1.1 


.5 . . 


.6 


.5 


trace . . 


— 


trace 


.5 .. 


1.6 


.5 


1003.5 . . 


1004 


. . 1003 



Water, .... 

Chloride of sodium, 
Phosphate of ammonia, 
Acetate of ammonia, . 
Hydrosnlphate of ammonia, 
Extractive matters, 

Specific gravity, . 

The first was from a man aged thirty-six, suffering from atonic gout; 
the second was also from a patient with gout; and the third from a 
girl of twenty-two, laboring under paralysis of the lower limbs. 

Of the abnormal constituents which have been found in the perspi- 
ratory fluid are, albumen in rheumatic fever, gastric, putrid, and hectic 
diseases, and also on the approach of death ; blood, uric acid, bilin 
and biliphaein, uro-erythein, and fat. "The following substances enter 
into, and have been detected in the sweat : quinine, sulphur, mercury, 
iodine, iodide of potassium, assafoetida, garlic, saffron, olive oil, rhu- 
barb, indigo, Prussian blue, and copper." 2 

Treatment. — I have several times been consulted in cases of osmi- 
drosis, and have succeeded in relieving my patients from a most dis- 
tressing malady, by a plan of treatment directed to regulate the secre- 
tions and other functions of the body. In one case, where the general 
means had failed, tannin effected a perfect cure. Locally, the chloride 
of lime lotion, or a solution of the permanganate of potash (Condy's 
fluid) will be found of service. 

CHROMIDROSIS. 3 

JSphidrosis discolor, Mason Good. 

Numerous instances of abnormal coloration of the perspiratory 
secretion are scattered through the works of the older medical writers, 
and through the various periodicals. Cases of blue perspiration 4 have 

1 Simon's Animal Chemistry, vol. ii. p. 108. 

1 Simon quoted from Stark's General Pathology, p. 1127; and Baumgartner, Elements 
of Physiology and Therapeutics, p. 486. 

3 Der. %pa/u*, color. 

* Conradi. Blue perspiration of one-half the scrotum, Anat. p. 292. Lemery, Histoire 
de 1'Acadfemie des Sciences, 1701. Fontenelle, sur les sueurs bleues; Journal de Chimie- 
medicale, vol. i. p. 330. Billard, Frorieps Notizen, No. 32. Dr. Bleifuss in Wurtemburg 
Medical Correspond. Blatt. 1835. No. 26. The occurrence of blue pus has been noted 
by several observers; amongst others, by Dr. Apjohn, of Dublin, and Dr. Olioli. Dr. Apjohn 
considered the color to be occasioned by the presence of Prussian blue. In Dr. Olioli's 
case, M. Bouchardat detected an organic coloring matter of unknown nature. Dr. Sem- 
mola has recorded two cases of blue urine. The coloring principle of blue perspiration 
is probably of a similar nature. 



DISEASES OF THE SUDORIPAROUS ORGANS. 551 

been recorded by several authors. Green perspiration 1 has also been 
observed, as have those of a saffron and ruby color. The rarest of the 
discolorations of the perspiration seems to be that in which the secre- 
tion is yellow. 2 Black 3 is not so uncommon ; it was probably of the 
same nature as the disorder described in a future page of this work, 
under the name of stearrhcea nigricans. 

In a case of green perspiration recorded by Mr. Pritchard, 4 of Lea- 
mington, the cause was ascertained to be the accidental exhibition of 
copper with the food, the food having been prepared in a copper ves- 
sel plated with tin, from which a portion of the tin had been rubbed 
away. The subject of the affection was a young lady of fourteen, 
who "had for some months evinced much general debility." She was 
then "seized with an attack of rheumatic fever, which yielded to 
remedies slowly and unsatisfactorily. After some days, during which 
the perspiration wasconsiderable, my attention was called to a collec- 
tion of light green perspiration between the toes, and underneath the 
nails of the young lady's feet, whilst the same appearance was observ- 
able in a fainter degree on the upper, but more especially the under 
surface of the foot." 

Treatment. — I have never seen a case deserving of being considered 
as one of chromidrosis. Were such a case to present itself, I should 
not doubt of being able to restore the healthy functions of the skin, by 
regulating the general health, and using stimulants locally. 

H^MIDROSIS. 

Eijhidrosis cruenta, Mason Good. Bloody sweat. 

The most common of the morbid discolorations of the perspiration 
are those of a red hue, which probably owe their peculiar tint to the 
coloring principle of the blood ; hence they appear to me to call for 
separate consideration. Landerer 5 observed a red perspiration which 
flowed from the axilla of a patient laboring under fever. Voigtel, 
also, has noticed an instance of sanguineous perspiration. 6 M. du 
Gard has recorded the case of a child three months old, that was " taken 
with a bleeding at the nose and ears, and in the hinder part of the 
head, which lasted for three days, and afterwards the nose and ears 
ceased bleeding, but still bloodlike sweat came from the head. Three 
days before the death of the child, which happened the sixth day after 
it began to bleed, the blood came more violently from its head, and 
streamed out to some distance. It also bled on the shoulders and at 

1 Borellus, Hist, et Obs. Med. Phys. Cent. 2. Observatio 54. Paullini Cent. 1. Ob- 
servatio 'is. John Peter Franck, De curandis hominum morbis. Landerer mentions an 
instance of green milk, secreted by the peripheral lobules of the mammary gland in a 
pregnant woman. 

■ Ephe rid. Nat. Cur. Deo. 1. Ann. G et 7. Obs. 78. 

8 BartholiDus, Acta. Hafn. 1. Obs. 70. Epbemerid. Nat. Cur. Dec. 1. Ann. 2. 
Obs. 19. 

* London Medical Gazette, vol. ii. p. 211. 1833. 

5 Buchner's Repertorium, 2d Series, vol. v. p. 231, quoted by Simon. 

6 Stark's General Pathology, p. 1131. 



552 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

the waist." "It bled also for three days at the toes, at the bend of 
its arras, at the joints of the fingers, and at the fingers' ends." 1 

The greater number of cases of effusion of blood, or of a sanguine- 
ous fluid from the skin, occur in young women, and are referable to 
vicarious menstruation. I once saw a young lady, in whom a dis- 
charge of this nature took place every fortnight from four circular 
spots, each about the size of a half-crown, and situated symmetrically 
on the face ; one being on each cheek, one on the forehead, and one 
on the chin. And more recently I have seen another young lady of 
highly nervous temperament, whose face would become in a few hours 
covered with blotches of blood without any lesion of the surface. 
When I sponged away the blood the skin looked congested and ery- 
thematous. In the "medical cases" above quoted, a young woman of 
eighteen suffered a loss of blood from "her ears, a little after at the 
points of her fingers, and then at her toes ; presently after, at the 
umbilicus and corner of the eye ; several times by sweat ; and at 
length it burst out from the middle of her breast ; afterwards in the 
foot, where the saphena is pricked in bleeding ; then at both palms 
and back of her hands. Two days after, it flowed from her chin, and 
in the night-time from the tip of her tongue, and all this in a fortnight's 
time." Whenever it flowed from her "breast or other parts like sweat, 
there was no vestige of an orifice to be seen." 2 

Mason Good remarks, that ephidrosis cruenta, which he defines as 
"cutaneous perspiration intermixed with blood," has "taken place 
occasionally during coition ; 3 sometimes during vehement terror, and 
not unfrequently during the agony of hanging or the torture. 4 It is 
said also to have occurred in some instances in new-born infants, 5 
probably from the additional force given to the circulation, in conse- 
quence of a full inflation of the lungs, accompanied with violent 
crying." 

Treatment. — The treatment of hgemidrosis depending on a he- 
morrhagic diathesis, must be regulated according to the various indi- 
cations which present themselves. When the cause is imperfect uterine 
function, the treatment must be the same as for amenorrhoea. 

1 Medical Essays, abridged from the Philosophical Transactions, vol. i. p. 52. 

2 Landerer mentions an instance of red milk secreted by a woman suffering under sup- 
pressed menstruation. 

8 Paulini, Cent. 3. Obs. 46. Ephemerid. Nat. Dec. 2. Ann. 6. Appendix, pp. 4, 
45, 55. 

4 Bartholinus, Epistola, i. p. 718. 

6 Ephemeridse naturse curios : Dec. 2. Ann. 10. Obs. 65. 



DISEASES OF THE SEBIPAROUS ORGANS. 553 



CHAPTER XXL 

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN. 
DISEASES OF THE SEBIPAROUS ORGANS. 

The sebiparous glands are subject to the same pathological laws 
that govern other secreting glands. The secretion may be increased, 
diminished, or altered, without manifest disease of the structure of 
the glands and their excretory ducts. Fourthly, the altered secre- 
tion may be accompanied by distension of the tubular structure of 
the glands and of their related hair-follicles. Fifthly, the glands, 
with their immediately adjacent tissues, may be the subject of inflam- 
mation, the secretion being at the same time more or less altered. 
Sixthly, they may be the subject of carcinomatous disease, constitut- 
ing a malignant tubercle. And in addition to these changes affecting 
the function of the glands, their structure may also undergo a patho- 
logical alteration. 

The follicles of the skin, with their excretory apertures, the pores, 
belong equally to the sebiferous and to the capilliferous system. 
Observation of the mode of development of these organs has shown 
that the formation of the follicle precedes that of the hair, and in like 
manner that the sebiparous gland is an offset from the neck of the 
follicle ; and further, that the sebiparous gland is not unfrequently 
composed of lobes which constitute a kind of frill around the neck of 
the follicle at no great depth from the aperture of the pore. These 
points of anatomical detail must be fixed in the mind for the proper 
understanding of a morbid affection, a peculiar alteration in the 
structure of the follicles, presently to be described. 

Again, the follicle is known to be composed of two parts, a vascular 
portion constituting part of the structure of the derma, and an epithe- 
lium, which belongs to the economy of the epidermis. It is perfectly 
consistent with analogy, that these two parts may be separately in- 
fluenced by morbid action, and that alterations of structure may take 
place that may be referable to one or other of them. Two such alter- 
ations I have noted as occurring in the epithelium of the follicles ; 
and as one of the two involves especially the epithelium of the sebifer- 
ous glands, I have selected the present chapter for their consideration. 

It is easily demonstrated that the epidermis forms a solid conical 
process which occupies the mouth of the dermal portion of the follicle. 
It is this solid cone of epiderm that gives transparency to the sum- 
mit of the papula of lichen, and suggests the idea- of the presence of a 
fluid. Normally this epidermal cone is not visible from the exterior ; 
but a case at present under my treatment offers the singular phe- 
nomenon of an hypertrophy of the epidermal cone, and its projection 



554 DISEASES OF SPECIAL structure of the skin. 

above the level of the surface, as a prominent papule of considerable 
dimensions. This morbid affection exists in a gentleman in good 
health, and occupies the upper extremities, principally the forearms, 
■where the skin is studded over with some hundreds of horny papulae, 
hemispherical in figure, yellowish in color, smooth, transparent, and 
extra-vascular, each papula presenting on its summit the aperture of 
a pore. The epidermis in this case is perfectly normal in structure ; 
and the disorder appears to me to be fittingly represented by the 
term, — papular hypertrophy of the epidermis of the cutaneous follicle 
(papulae epidermicae vel epidermidis). The part of the epidermis 
specially constituting the morbid phenomenon is not the rete mucosum, 
but the horny layer. 

Another disorder of the epithelium of the follicles of the skin is 
more common than the preceding, and involves chiefly its deeper 
layer, spreading when it reaches the surface into the rete mucosum 
of the epidermis. The pathological nature of this affection is an 
hypertrophy and altered color of the epithelium of the sebiparous 
gland and of its excretory tubuli. The epithelium is thicker than 
usual, of a spongy texture, and yellowish in color, and lifts up the 
tissues immediately around the pores into rounded papulae of con- 
siderable size, which are sometimes discrete and sometimes coherent. 
The papulae are smooth, hemispheroidal, sometimes flattened on the 
summit, perforated by the aperture of a pore, elastic, insensible, and 
of a buff or nankeen } r ellow color. To the eye they suggest the idea 
of a yellowish tubercular or cheesy matter deposited beneath the 
cuticle, but a puncture proves them to be solid and vascular, in con- 
sequence of the vascular parietes of the gland being carried upwards 
to the surface by the growth of the morbid epithelium. They have 
no tendency to suppurate or ulcerate, but remain permanently on the 
skin, sometimes increasing slowly in size. In pathological nature, 
these papulae may be designated a yellow hypertrophy of the epithelium 
of the sebiparous glands, and are deserving of the title of papulce flavce 
epithelii cutis. In a gentleman, at present under my care, suffering 
from a chronic syphilitic affection of the tongue and palms of the 
hands, a crop of these papulae flavae are dispersed over the forearms, 
chiefly on the anterior surface ; a few are developed on the backs of 
the hands ; there is a small cluster of coherent papules on the point of 
the elbow, and several on the pinna of the ear. In my remarks on 
this case, I find that on his first visit to me I noted the eruption as a 
molluscum sebaceum ; but further observation induced me to alter my 
opinion as to the nature of the disease, in accordance with the views 
now put forth. 

The commonest situation of this affection is the integument of the 
eyelids (Plate XX., figs. 2, 3); and there the disorder more frequently 
appears as plates of irregular dimensions than as papulae. It is in the 
eyelids that we most frequently have the opportunity of observing 
the extension of the morbid change in the epithelium to the rete 
mucosum ; and it is there more or less extensive in its distribution. 
This disorder appears more commonly in women than in men ; after 
the mid-period of life than in youth ; and is commonly permanent. 



DISEASES OF THE SEBIPAROTJS ORGANS. 555' 

It presents considerable variety in tint of color, being sometimes 
cream-colored, or a light buff, and sometimes of a bright golden 
yellow; it also offers some differences of surface, having reference to 
its discrete or confluent origin, and to a disposition to spread more or 
less actively to the neighboring rete mucosum. In the former case 
(fig. 3), it preserves its papular character, and has a granular appear- 
ance ; in the latter (fig. 2), it is smooth. This affection was described 
some years since by Dr. Gull in the Guys Hospital Reports, under the 
name of Vitiligoidea; the papular variety he called V. granulosa; 
and the smooth variety V. plana. The name was suggested by the 
discoloration of the skin in patches, but is not a happy designation, 
as the disorder has no relation to the disease termed vitiligo; the 
morphoea, which is a companion of elephantiasis. Following up the 
idea of papulae flavse epithelii cutis, as applied to the discrete variety, 
I should call the confluent kind, as it appears on the eyelids, lamince 
flavce epithelii cutis, and the granular and the smooth kinds might be 
distinguished as papulosse or granulosse, and planes. 

Dr. Gull believes he has traced some relation between this disorder 
and a morbid state of the liver; and the fact of the occurrence of the 
disease after the mid-period of life, and its association with an 
accumulation of yellowish and dusky pigment in the rest of the 
skin, are circumstances favoring this hypothesis. On the other 
hand I must remark, that I have twice seen it in young women in 
whom there was no symptom of torpid action of liver present. The 
most extensive case I have met with occurred in a young woman who 
was perfectly healthy in all her functions. Again, it is remarkable 
that the disorder is almost exclusively confined to women. 

The treatment of this complaint suggests local stimulation, with a 
view to modify the innervation and nutrition of the skin; and con- 
stitutional remedies of an alterative kind. I succeeded in removing 
the disorder in one patient by the daily application externally of the 
compound tincture of iodine; and by the internal exhibition of 
Fowler's solution of arsenic; and I should recommend a trial of these 
remedies in similar cases. Generally, patients are little inclined to 
give themselves any trouble with regard to it, as it occasions no pain, 
and no inconvenience beyond its somewhat remarkable appearance. 

I. AUGMENTATION OF SECRETION. 
STEARRHCEA SIMPLEX. 

Syn. Sebaceous flux. Seborrhoea. Cutis unctuosa. 

Great diversity exists among individuals, in relation to the quantity 
of sebaceous secretion naturally poured out upon the surface of the 
skin. In certain instances we have occasion to remark a great increase 
of this secretion, particularly during the progress of constitutional 
affections in which the activity of the cutaneous circulation is excited. 
When this condition is present, the skin is bedewed with an oily fluid, 
which is especially abundant on the nose, face, and head, and upon all 
those parts of the body in which the glands are present in considerable 



556 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

number. -The augmented secretion, after continuing a variable length 
of time, gradually diminishes without requiring medical treatment, 
and without giving rise to any unpleasant symptoms, further than 
those which are necessarily associated with the unsightly appearance 
of a greasy skin. This affection may be often seen in persons other- 
wise enjoying excellent health, in whom an over-stimulating diet, or 
some slight disorder of digestion, can alone be assigned as a probable 
cause. At other times it depends on torpor of the skin, and is asso- 
ciated with general torpor of the whole system. 

In more severe cases of the sebaceous flux, the skin is somewhat 
congested and thickened, the common apertures of the excretory ducts 
and hair-follicles are enlarged, and the secretion poured out spreads 
in considerable quantity on the epidermis. This profuse form of the 
disease is usually met with on the face, continues for a great length of 
time, and evinces no disposition to improve without medical treatment. 
Such cases are accompanied with pruritus, and often with severe 
shooting pains. 

Treatment. — Attention to regimen, laxatives, alterative doses of 
mercury, tonics, the fulfilment of such peculiar indications as the state 
of health of the patient may offer. Locally, the free use of soap 
with astringent lotions, such as the bichloride of mercury lotion, with 
emulsion of bitter almonds; or the juniper tar soap. 

II. DIMINUTION OF SECRETION. 
XERODERMA. 

The term xeroderma (Sypte, aridus), or simply, dry skin, is intended 
to convey the idea of a condition the opposite of the preceding ; an 
affection which is occasionally met with in elderly persons, and some- 
times in children and adults. The natural consequence of diminished 
function of the sebiparous glands is a disagreeable dryness and 
harshness of the skin, with their usual accompaniments, cracking and 
desquamation of the epidermis. This state of the glands sometimes 
originates in neglect of personal cleanliness, but, in most instances, is 
due to natural predisposition. When the former is the cause, the 
bath, frequent ablutions with soap, and plentiful frictions with a rough 
towel, are the proper expedients for procuring relief. Indeed, in every 
case, frequent sponging of the skin and friction are advantageous. 

When xeroderma exists in a more severe and complete state, it 
constitutes the affection known as ichthyosis, the fishskin disease. 

XERODERMA ICHTHYOLDES. 

Syn. Ichthyosis vera; simplex; vulgaris; congenita; mollis; fur- 
furacea; reticulata; nitida; serpentina. Lepidosis ichthyosis, Mason 
Good. Ichthyose nacree. Fischschuppenaussatz, Germ. Fishskin 
disease. 
That diseased state of the skin to which the term ichthyosis, or 

fishskin disease, has been applied, is greatly confused in the writings of 



DISEASES OF THE SEBIPAROUS ORGANS. 557 

different authors, from the want of a distinction between two obvious 
forms which the disease is apt to present. In one of these, to which 
I have given the term xeroderma ichthyoides, and which may very 
properly be called ichthyosis vera, the epidermis is the seat of the 
morbid alteration ; while in the other, which I have termed ichthyosis 
sebacea, and which may also be denominated ichthyosis spuria, the 
morbid appearances are due to the presence of the sebaceous secre- 
tion altered in its quantity and quality, and deposited on the surface 
of the skin. 

The characters of xeroderma ichythoides are, a general dryness 
and roughness of the skin ; modified in appearance in different 
regions of the body. On the cheeks and forehead the epidermis is 
comparatively smooth, but presents a number of ragged edges, the 
result of constant exfoliation ; around the mouth and eyelids, and on 
the neck, it is rough, and has a mealy or branny appearance, 
ichthyosis furfur acea ; and on the rest of the body the breaking up of 
the epidermis corresponds with the direction and form of the lines of 
motion of the derma. The pores of the follicles, both sebiferous and 
capilliferous, are prominent from the accumulation within them of a 
dry hardened substance, of which a portion often projects beyond the 
level of the aperture. This desiccated substance is the epithelial 
lining of the follicle, altered in its character by the absence of its 
oleaginous element. The hair undergoes a similar change ; it is 
either wanting altogether, or it is dry and brittle, and broken off on 
a level with the skin. 

The texture of the skin exhibits throughout a state of defective 
nutrition ; this is least conspicuous in the face, but is very apparent 
in the limbs, and particularly in the arms ; and there is besides a 
marked deficiency of subcutaneous adipose tissue. The skin is 
sometimes thinner, and sometimes thicker than natural, sometimes 
soft, and sometimes hard. When soft it may be pinched up from the 
parts beneath in a remarkable manner, and in the different movements 
of the limbs is thrown into folds which have more the character of 
a loose vest than of a part of the body. When the skin is hard 
it cannot be pinched up, but it may be moved backwards and 
forwards on the subcutaneous fascia, as if there were no binding 
tissue between the under surface of the corium and the structures 
beneath ; and, instead of falling into folds during the movements of 
the body, it remains stiff like leather, and seems to depend entirely 
upon the lines of motion for its power of adaptation to the movements 
of the joints. The lines of motion are therefore very strongly marked, 
and form deep grooves, while the inflexible arese between them are 
large and smooth. The softer condition of the skin is met with on the 
neck, the limbs between the joints, the flexures of the joints, and the 
trunk of the body; the harder condition on the hands and feet, and 
the convexities of the joints. 

In a case which I have illustrated among my Portraits of Diseases of 
the Skin, 1 the subject was a little girl between five and six years of age, 

1 Plate XXXVII., S. 



558 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

and small of stature ; her face was polished and moderately full, of a 
dirty hue, and roughened by ragged edges of broken and exfoliating 
epidermis. The skin of the rest of the body was dry and wrinkled, 
and around the joints was thrown into folds, looking as if much too 
large for the body which it contained, or like the parched and 
shrivelled integument of a person of extreme age and decrepitude. 
The general tone of color of the skin was a yellowish gray, but the 
hands were red ; gentle pressure with the finger dispersed the redness 
to a considerable distance around the compressed spot, rendering it 
perfectly white, and the color was slow in its return. The skin of the 
backs of the hands and fingers was thicker than natural, hard, like 
parchment, and divided by deep grooves into large and irregular 
compartments ; this was especially the case upon the knuckles, and 
every here and there the skin had broken in the lines of motion, and 
formed deep chaps. The skin of the palms of the hands exhibited the 
thickening of the derma, the parchment-like yielding of the unpliant 
tegument, the large compartments, and the deep grooves, more strongly 
than that of the back, and there were besides deeper fissures and 
cracks. At the metacarpophalangeal joints the fissures were so deep 
as to .sever the integument completely. There was another singular 
peculiarity apparent in the hands, namely, a want of proportion in 
length between the skin and the bones, so that the knuckles of the 
metacarpo-phalangeal articulation made their projection very near the 
middle of the hand, as though the metacarpal bones had not grown in 
accord with the integument, or as though the fingers in their growth 
had carried with them the integument of the body of the hand. This 
appearance may be imitated by drawing a glove forward on the fingers, 
and then closing the hand. 

The lower limbs were highly characteristic of the disease. The skin 
of the knees was thrown into numerous prominent wrinkles, on which 
the epidermis was harsh, dry, thick, and discolored, and in certain 
parts, where the wrinkles were crossed by transverse clefts, resembled 
ichthyosis cornea. On the sides of the knee, near the ham, a similar 
structure existed. From the knee to the ankle the skin was smooth, 
grayish, silvery,' and glossy, ichthyosis nitida, and in an oblique light 
might from its refractive qualities, bear comparison with mother-of 
pearl (ichthyose nacre'e, Alibcrt). It was marked by a reticulated 
tracery of white lines, ichthyosis reticulata, the lines being occasioned 
by the loosening and rupture of the epidermis at the abnormal grooves 
of motion of the condensed skin. The spaces between the reticula- 
tions, from their regularity of shape and smooth polish, resembled more 
or less closely the silvery scales of certain fish ; hence the name of the 
disease ; and occasionally, when the reticulations were of small size 
and irregular, and the centre of each scale thicker and more deeply 
colored than its border, the idea of the scales of serpents was sug- 
gested, ichthyosis serpentina. Around the ankle the skin was thrown 
into prominent wrinkles, and across the instep were three grayish 
bands, where the epidermis was thicker than natural, and marked by 
a number of longitudinal clefts into broken ridges running parallel 
with the foot. On the rest of the back of the foot the skin formed 



DISEASES OF THE SEBIPAROUS ORGANS. 559 

numerous wrinkles corresponding with the movements of the joints, 
and along its borders were several deep chaps. The soles of the feet 
exhibited the same peculiarity as the hands, namely, a disproportion 
in growth between the skin and the bones. This was apparent in the 
great length of the foot and the shortness of the toes. The epidermis 
of the under surface of the foot was very thick, yellowish in color, 
very much broken, and presented a number of irregular edges ; on 
the borders of this surface were several deep and long chaps. 

In adults, the apparently normal state of the face, the dry, wrinkled 
and mealy state of the skin of the limbs, and the absence of sub- 
cutaneous fat, are quite remarkable. Sometimes, however, the face 
has a peculiar coppery redness and an oily polish, which contrasts all 
the more with the earthy, dried, and mealy or scaly epidermis of the 
rest of the surface. The skin of the hand is also remarkable for its 
coarseness, and the hand of the ploughman is met with in the man of 
refinement, to whom manual labor is unknown. In ladies, also, the 
dry, leathery, wrinkled skin of the hands is very striking. I 
recollect well the shudder that passed over me when I saw this 
disease for the first time. It was in a gentleman of twenty-five or 
thirty ; in appearance, in freshness of face, and roundness of feature, 
one would have believed him perfect in every point. He took on his 
coat suddenly, and drawing up the shirt sleeve, exhibited the withered 
limb of sordid age ; dry, scaly, polished here, mealy and rough there, 
while a cloud of small micaceous scales flew into the air. 

Another character in connection with this disease is interesting in a 
physiological point of view. From the absence of all secretion, or at 
least great deficiency of secretion, from the skin, the circulating 
system loses a natural source of relief when in a state of excitement. 
Hence active movement is attended with increased rapidity of respira- 
tion and action of the heart ; and one of my patients informed me that 
after a dance he panted for breath, he had violent palpitation of the 
heart, and his brain seemed to reel, from want of air, and from a 
feeling of suffocation. 

The diagnosis, the prognosis, and the cause of xeroderma ichthyoides, 
may be very briefly stated. The general dryness of the whole of the 
skin is entirely distinct from lepra, which is never general, and 
always leaves a greater or less extent of sound skin between its 
patches. From psoriasis, xeroderma is distinguished by the absence of 
erythema and all signs of inflammation; although erythema may, as a 
matter of course, be superadded to this disease as an accidental 
complication; but there is a wide distinction between a congenital 
defect of nutrition of the skin and a disease subsequently acquired. 
The prognosis of xeroderma ichthyoides is favorable; much may be 
done by treatment, even if the skin cannot be restored entirely to the 
Btate of. that of a person who has never been so afflicted ; and I can 
point to several cases in proof. The cause of the affection is con- 
genital mal-nutrition, sometimes probably the result of mal-assimilation, 
commencing soon after birth. 

Treatment. — The treatment of xeroderma ichthyoides is twofold, 
constitutional and local. After the general functions of the body 



560 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

have been regulated by the usual means, the patient should be put 
under a course of cod-liver oil and arsenic ; I have usually selected 
for the purpose the arseniate of soda, or Fowler's solution ; but in 
some instances have derived advantage by changing those remedies 
occasionally for Donovan's solution. Locally, the treatment should 
consist of frictions with fresh and sweet neat's-foot oil; the inunction 
and friction should be made night and morning, and continued for as 
long a time as the patience or leisure of the individual will permit. 
For children I prescribe a friction of half an hour or an hour's dura- 
tion. When the skin is softened and made pliable by the oil, the 
force of the friction may be increased by the use of the Indian flesh- 
glove or kheesah, 1 instead of the hand. A tepid soap-bath may be 
taken once or twice a week, and a cold shower-bath, or sponging-bath 
every morning on first rising, the bath being preceded and followed 
by the frictions. Sometimes, particularly in children, and in adults 
where there arose a difficulty as to the full extent of the friction and 
inunction being employed, I have found it necessary to increase the 
stimulant effects of the local application, by the addition of liquor 
ammonise or croton oil, to the oil or ointment employed for that 
purpose. I may illustrate this method of treatment by. reference to 
the case of a little boy whom I treated in 1844, and who has since 
continued perfectly well ; but I must at the same time remark, that 
the rapid cure in this case is to be ascribed in some measure to the 
disease being taken at an early period of its existence, as well as to 
the correctness of the principle of management. 

When I saw him for the first time, I ordered him a soap ablution 
every night,' and an ointment to be well rubbed into the skin after 
the bath, and in the morning, as follows : 

R. — Olei olivse optatse, J;iv. 
Cerse albidas, ^ij. 
Liquefac simul dein adde — 
Mellis, 3ij. 
Olei Crotonis Tiglii, irjjxx. — M. 

I also prescribed for him a teaspoonful of sulphur sublimatum, 
with ten grains of supertartrate and five of nitrate of potash, twice 
a week. At the end of a month I increased the croton oil to thirty 
minims ; and at the end of a second month, to forty minims. By the 
conclusion of the third month the skin had almost regained the 
pliancy and softness of health ; the epidermis ceased to crack and 

1 The kheesah, or Indian flesh-glove, comes recommended to us by the experience 
of ages, and certainly offers advantages superior to any other kind of rubber for the skin 
in existence. It is the glove, or rather mitten, which has been used from time immemorial 
in Hindoostan, Persia, and throughout the East, and by a race of people, both from 
necessity and luxury, more attentive to the skin than any other upon the face of the globe. 
The glove was introduced into England by Sir Ranald Martin, of Grosvenor Street, and 
Messrs. Savory and Moore have succeeded in procuring the manufacture of a similar 
glove in London. Their imitation is perfect, both in appearance and properties; indeed 
is superior to the original; and it is satisfactory to me to be enabled to recommend so 
admirable a contrivance for promoting the health of the body through the agency of the 
skin. The glove is made of goat-hair, the material used in the manufacture of the 
Burruck or Persian glove cloth, of which the Oriental kheesah is composed. 



DISEASES OF THE SEBIPAROUS ORGANS. 561 

break up into dry scales, and the skin was so sound that I was ena- 
bled to dismiss him, enjoining a continuance of the soap ablution 
once a week, with cold sponging every morning, and the daily use of 
the kheesah. The ointment was now laid aside, as being no longer 
necessary. 

III. ALTERATION OF SECRETION. 

In addition to simple increase in quantity, it not unfrequently 
happens that the secretion of the sebiparous glands is altered in its 
quality. For example, it may be changed in color, and by its accu- 
mulation on the skin form a thin film of a yellow or black hue ; or it 
may be altered in consistence, and after being spread out upon the 
surface, dry into a hardened crust, which may break up into frag- 
ments corresponding with the linear markings of the skin, the frag- 
ments maintaining their adhesion to the epidermis, and increasing in 
size by subsequent deposition. These states of the sebaceous secre- 
tion constitute a small group of cutaneous disorders, which we will 
consider under the names of — 

Stearrhcea flavescens, 

Stearrhoea nigricans, 

Ichthyosis sebacea. 

STEARRHCEA FLAVESCENS. 

In this disorder the abnormal secretion is of a golden or dirty 
yellow color and forms a film on the surface, which gives the skin a 
coarse and disagreeable appearance. The substance is soft, and may 
be removed more or less easily from the epidermis ; sometimes it can 
be wiped away with the handkerchief, but at other times adheres 
very tenaciously. When removed, it is produced again in the course 
of twelve hours, and in twenty-four hours regains its original thick- 
ness. The seat of this affection in the cases which have come under 
my observation, is, the nose, cheeks, and scalp. The subjects of the 
disorder on the face were ladies ; while the affection of the scalp, 
though more common in women than in men, I have seen in both. 

Stearrhcea flavescens sometimes assumes a chronic character, and 
the abnormal secretion, instead of being soft and removable "by ablu- 
tion, forms a hard and dense crust, which adheres firmly to the skin, 
and can only be separated by means of the water-dressing. The 
skin becomes secondarily diseased in consequence of the irritation 
caused by this crust, and the affection puts on a troublesome charac- 
ter. A case of this kind, at present under my care, has existed 
for six years, and was originally excited by exposure to the heat of 
the sun. 

STEARRHCEA NIGRICANS. 

The abnormal sebaceous substance poured* out upon the skin has 
occasionally a grayish appearance ; and in some instances is perfectly 
black. In other respects, namely, as relates to consistence and 




062 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

thickness, it resembled the deposits which are formed in stearrhoea 
flavescens. 

Examined with the microscope, I found this deposit to correspond 

with ordinary sebaceous substance, but the nuclei of the 

Fig. P. cells, instead of being colorless, were black, and every 

here and there formed masses of considerable size. Indeed 

they were identical in point of structure with the deepest 

colored cells of the rete mucosum of the negro skin ; the 

nuclei being composed of an aggregation of granules more 

or less shaded with pigment. These appearances corres- 

with what I had previously observed in some black matter 

removed from the skin of the face by Mr. Gregory Forbes, in a young 

lady who was under the care of Dr. Maclntyre. 

In Dr. Maclntyre's case, the abnormal secretion could be removed 
by washing, leaving the skin beneath perfectly natural, and was 
reproduced in the course of twelve hours. In another case of this 
kind, which occurred to Mr. Teevan, and of which an account, with 
a drawing of the appearance of the patient, is published in the twen- 
ty-eighth volume of the Medico- Chirurgical Transactions, the skin 
was so sensitive, that the young lady was induced to abstain from 
any attempt at washing away the secretion ; and each fresh effusion 
was preceded by a pricking and burning heat. The most remarkable 
features in the case of Mr. Teevan's patient are the suddenness with 
which the effusion took place after the skin was perfectly cleared, and 
the occurrence of black vomitings, black dejections from the bowels, 
and a black pigment in the urine, when the secretion on the face was 
arrested. The young lady who was the subject of this unpleasant 
affection had been under the care of Dr. Read, of Belfast, for a severe 
pain in her side. At that time the cutaneous affection had not 
attracted much attention, and Dr. Read was of opinion "that it was 
connected with imperfect menstrual function." 

In an analysis of the black secretion from this patient, made by Dr. 
G. 0. Rees, it was found to be composed of carbon, iron, lime, albu- 
minous matter, fatty matter, and chloride and phosphate of soda. 

In a case at present under my treatment, the blackness is confined 
to the eyelids and adjacent sides of the nose, giving to the young lady 
who is the subject of this annoying affection, the appearance of having 
extensive ecchymoses of the eyelids (Plate XX., fig. 1). When the 
discoloration is coming on, she has a sensation of fulness about the 
eyes, with slight indistinctness of vision and a little headache. The 
discoloration is usually greatest in the evening, and is subject to 
increase with anxiety or fatigue. When wiped with a cambric hand- 
kerchief, the handkerchief is soiled. 

It is more than probable that some of the cases of black perspiration 
recorded by the older writers were of the same nature as the cases 
quoted above. The following instance of a similar disorder is pub- 
lished in the Philosophical Transactions, by Mr. Yonge. " A girl, 
sixteen years old, a daughter of Mrs. Elizabeth Worth, of Plymouth, 
about the end of April, 1709, had a few hot pimples rose on her 
cheeks, which bleeding and a purge or two cured. She continued 



DISEASES OF THE SEBIPAROUS ORGANS. 563 

very well till about a month afterwards, when her face, so far as is 
usually covered with a vizard mask, suddenly turned black like that 
of a negro. This surprising accident much frightened her, especially 
after some foolish people persuaded her she was bewitched, and never 
to be cured. By prayers, exorcisms, &c, which they used, in order 
to relieve the fascination, they increased the passion and terror of 
mind to a great degree, even to distraction, and then desired my 
assistance. By the arguments which I used, and some composing 
anti-hysterical remedies, the violence of her fits became much pacified. 
I directed a lotion for her face, which took off the discoloration ; yet 
it returned frequently, but with no regularity; sometimes twice or 
thrice in twenty-four hours, sometimes five or six times. It appears 
insensibly, without pain, sickness, or any symptoms of its approach, 
except a little warm flushing just before it appears. It easily comes 
away, and leaves the skin clear and white, but smuts the cloth that 
wipes it from the face; it feels unctuous, and seems like grease and 
soot, or blacking, mixed. It has no taste at all. She never had the 
menses; is thin, but healthful; the blackness appears nowhere but in 
the prominent part of her face. There are a thousand eye-witnesses 
to the truth of this uncommon case. The anomalar blackness of the 
girl's face is now (November 1) divided into a few dark cloudy specks, 
which appear but seldom, and nothing so livid as formerly." 

% ICHTHYOSIS SEBACEA. 

Sauriderma. Ichthyosis spuria. 

Just as the term ichthyosis vera, or xeroderma ichthyoides, has, in 
a preceding section, been applied to a state of the skin in which the 
epidermis is broken up into compartments, or scales, which have been 
compared to the scales of a fish; so, the term ichthyosis sebacea, or 
ichthyosis spuria, is now employed to designate the production of 
scales, or horny masses, consisting of desiccated and altered sebaceous 
substance, and more or less generally distributed on the skin. In 
xeroderma ichthyoides the scales are thin, and have a certain bright- 
ness and splendor which gives a warrant to their comparison with the 
scales of a fish; but this is not the case in ichthyosis sebacea. In the 
latter disease, the scaly masses are thick, more or less convex and 
prominent, grayish or brownish in color; in a word, more like the 
scales of the saurian reptile than the fish; hence, a more proper desig- 
nation for this disease would be sauriderma. 

Sauriderma conveys at once the idea of a state of the skin resem- 
bling that of the aabpos, laccrtus, which is the most correct notion that 
can be given of the disease by a single word; while it prevents the 
confusion which must always result from the consideration of two 
essentially different diseases, one involving the epidermis, the other 
the secretion of the sebiparous glands, under the same common term, 
namely, ichthyosis. Xeroderma and sauriderma distinguish two es- 
sentially different pathological states of the skin. 

Ichthyosis sebacea, or sauriderma, presents two principal varieties, 
one in which the scales or horny masses are not much raised, and are 



564 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

either squamiform or irregular in shape; and another, in which the 
horny masses are lengthened considerably, and have the character of 
spines. They may be expressed as follows : 

Ichthyosis sebacea squamosa, 

Ichthyosis sebacea spinosa. 

ICHTHYOSIS SEBACEA SQUAMOSA. 

Sauriderma squamosum. 

We call that state of the skin ichthyosis sebacea squamosa, or sau- 
riderma squamosum, in which, after the effusion of the abnormal 
sebaceous substance in the form of a thin layer, the latter dries and 
hardens, and breaks in the direction of the linear markings of the 
skin, into small polygonal portions, corresponding in form with the 
arese of the compartments bounded by these cutaneous lines. The 
small polygonal divisions are increased in thickness by the accumu- 
lation of fresh sebaceous secretion, they become discolored from expo- 
sure to dust and dirt, and they assume a brownish or grayish tint, 
approaching more or less to dirt-color. In the latter state, the small 
masses have the appearance of scales, closely adherent to the epider- 
mis, hard and dense in texture, and presenting various degrees of 
thickness. This affection may occur upon any part of the body, but 
is most frequent on the face, particularly on the forehead and nose, on 
the abdomen, and on the flexures of joints; indeed, upon all those 
regions in which the greatest number of sebiparous glands exist, and 
which are most protected from the friction of dress. The scales are 
sometimes cast from time to time, as during the summer season, and 
give place to others formed by successive concretion; at other times 
they remain adherent for months, and even for years. 

This affection of the sebiparous glands is generally unaccompanied 
by signs of local inflammation of the skin. There is, in many cases, 
no redness, and no heat, and when the scales are thrown off, the skin 
is natural, both in color and texture; in others, the skin is congested 
and thickened; it is studded with numerous apertures of sebiferous 
ducts, and frequently painful. By accumulation, the scales obstruct 
the mouths of the excretory ducts, and the latter become much dis- 
tended. The disease is rarely accompanied with constitutional symp- 
toms, but in a few cases, when general, some degree of gastrointesti- 
nal irritation may be present. 

In one instance of this affection which fell under my observation, I 
had the opportunity of examining the skin after the death of the pa- 
tient from visceral disease. In this case, the scales were remarkable 
for their thickness; after being well washed, they were grayish in 
color upon the surface, but white beneath, and evidently consisted of 
concreted sebaceous substance. On removing a portion of the epi- 
dermis by maceration, the ducts of the sebiparous glands and hair- 
follicles were found distended with inspissated white secretion, and 
had a brilliant appearance, projecting like cones of pearl from the 
under surface of the membrane. The derma presented a number of 
small deep pits, corresponding with these dilated ducts. The mouths 



DISEASES OE THE SEBIPAROUS ORGANS. 565 

of the distended excretory ducts opened upon the surface of the epi- 
dermis, some immediately beneath and in the middle of the scales, and 
others by their borders. In the former situation, they could be seen 
as small white points through the scale, and still more evidently when 
the epidermis was separated by maceration. 

From the examination of this case, of which a preparation is now 
before me, and of others which I have subsequently observed, I have 
been led to the conclusion, that the scales, in this disorder, increase in 
thickness in two ways: firstly, by addition to the free surface, by 
means of the secretion poured out in the linear furrows of the skin, 
and, consequently, between the scales ; and secondly, by additions 
successfully made to the attached surface by the effusion of inspissated 
secretion beneath them. In the preparation before me, the growth of 
the scales by both these processes is distinctly evident. 

A case of this disorder, disseminated in patches over the surface 
of the head, neck, and trunk, is recorded by Dr. Jacobovics, 1 under 
the erroneous appellation of "tubercules bigarres," a new variety of 
molluscum. Dr. Jacobovics' case differs from ordinary instances of 
the disease, in the longer duration of the malady, its disseminated 
character, the excoriations which resulted from its continuance, and 
the presence of inflamed tubercles intermingled with the patches. 
The patient was a tailor, of bilio-sanguine temperament, fifty-six years 
of age, the nineteenth child of healthy parents. His mother had a 
slight cutaneous affection on the neck; a brother had furfuraceous 
desquamations on the face ; two sisters had small tubercles on the 
neck and bend of the elbow ; a sister's child had a similar growth. 
At the age of thirty he was attacked with severe pneumonia, which 
left him in unsound health for some years. On reaching his thirty- 
seventh year, the cutaneous disorder first made its appearance ; it 
commenced on the neck in the form of small yellowish spots, 
beneath which one or more white points, the apertures of sebiferous 
ducts loaded with secretion, were perceptible. These yellow spots 
gave rise to pruritus, during the summer season, which subsided in 
the winter. Three years afterwards, on the occasion of a severe 
mental affliction, the disease showed a disposition to increase, and 
quickly spread over his neck, breast, and back. The disorder now 
assumed the appearance of little crusts, 2 having a roundish or irregu- 

1 Du Molluscum, rocherehes critiques, &c, snivies de la description d6taillee d"une non- 
velle vari6te. Par M. M. Jacobovics. Paris, 1840. 

2 With no better reason, apparently, than that of adhering to the erroneous appellation 
which he had assigned to this disease, Dr. Jacobovics styles the crusts, tubercles, or tumors, 
throughout his essay. They were unquestionably extravasculai Formations, and mere 
depositions on the surface. In accordance with this view, I have, in every instance, 
altered the terms tubercle, or tumor, to crust. Besides, it does not accord with correct 
notions of pathology to admit the possibility of a tubercle, or tumor, being converted by 

tve development into a crust. But to agree with Dr. Jacobovics, such a doctrine 
must be embraced : for, after indicating a number of progressive stages of growth completed 
by the crust, he remarks, in conclusion, " Les tubercules bleuatres et noiratres, les cro&tes 
noires et verdatres, et les taclns <|tii Inn- succcdent sont des formes secondares." That is 
to say, thai the black and greenish crusts are the secondary forms of lv les tubercules bru- 
natres." Those who would peruse the statements of Dr. Jacobovics, I must refer to his 
essay presented to the " Academic lloyale " 



566 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

lar figure, and various color ; for instance, some were yellowish-white : 
others fawn-colored and brownish ; others blackish and livid, and 
covered with slight desquamation ; but there was no constitutional 
disturbance, nothing to induce the patient to apply for medical 
assistance until the year 1833, when, annoyed by the violent pruritus 
and unsightly appearance of the disease, he presented himself at Saint 
Louis. He was treated at this hospital for two months without benefit, 
and then returned to his business. Three months later his case was 
undertaken by Dr. Jacobovics, and presented the following charac- 
ters : 

His hair was remarkable for its greasiness, as were several other 
parts of his body, particularly the skin of the front of the neck, which 
the author describes as feeling viscous and unusually soft. At the 
roots of the hair were numerous yellowish patches and scales of 
sebaceous substance ; these greasy scales were als<3 met with dis- 
persed over many parts of the skin. On the forehead, the alee nasi, 
the cheeks, the back, and in several other situations, the apertures of 
the sebiferous ducts were very perceptible, and many of them were 
obstructed by inspissated secretion, which was dark-colored in some, 
yellowish in others, and rose above the level of the surrounding skin 
in several. In other situations the sebaceous substance retained its 
softness and whiteness, and, distending the excretory ducts, appeared 
like white points in the midst of the yellowish and discolored laminae 
by which its escape was prevented. The crusts commence by a 
whitish-yellow or brownish spot, of the diameter of a millet seed or 
lentil, but without prominence, and pass through a succession of 
stages which the reporter has accurately detailed. The yellow spot 
is attended with pruritus, and, examined with a lens, a minute white 
point may be discerned in the centre of each. In a more advanced 
stage, the yellow spot has increased in diameter, and is raised in the 
centre, when it presents three or four white points in place of one. 
By degrees the yellow spots become transformed into brownish 
crusts, having a maximum elevation from the surface of two lines, 
and a maximum diameter of six lines. These brownish crusts 
appear studded beneath the surface with white sebaceous points, 
which give the mottled (bizarre") character to the production, which 
suggested to Dr. Jacobovics the specific name which he has given the 
disease. The succeeding stages which the author has observed the 
sebaceous concretions to assume, are, bluish crusts, punctated with 
white, and having a lobulated appearance, occasioned by the linear 
markings of the skin ; and blackish crusts, punctated only around 

1 Dr. Jacobovics speaks of patches of a dirty yellow, or yellowish-white color ; these 
patches he seems to regard as discolored epidermis, and lie describes the white points as 
being beneath the epidermis. From the observation of cases of this kind, and particularly 
Of the one recorded above, I feel convinced that the yellow patch is a thin layer of inspis- 
sated sebaceous substance adhering very closely to the epidermis; this I conceive to be 
gradually raised by the deposit of fresh sebaceous matter beneath it, until the elevated crusts 
are formed, which are the distinguishing feature of this case. The white points will, con- 
sequently, be seen beneath the sebaceous scale. I have already alluded to this appear- 
and-, and have before me a preparation in which it is well shown. 



DISEASES OF THE SEBIPAROUS ORGANS. 567 

the edges, and intersected by deeper furrows, corresponding with the 
dermal lines. These latter were chiefly met with in the dorsal region; 
after a time, the linear furrows increase in depth, even to the splitting 
of the crust into a number of small polygonal masses, 1 which adhere 
firmly to the epidermis, and assume a deep black color. The desic- 
cated patches, rubbed by the dress, or scratched with the nails, are 
liable to excite suppuration of the derma, and the pus, oozing from 
between the fractured masses, forms upon the surface a succession of 
irregular crusts, which resemble those of impetigo. Other crusts, of 
a yellowish-green color, are also met with, resulting from the imme- 
diate desiccation of the brownish punctated patches, and these also 
become broken in the direction of the natural furrows of the derma. 

Besides the sebaceous crusts above described, there were inter- 
spersed on this man's skin a number of small tumors and tubercles. 
Some of these were round or oval, prominent in the centre, of a bright 
red color, smooth and shining, covered by a thin and desquamating 
epidermis, and the seat of a troublesome pruritus. Others were of a 
bluish-gray color, with raised and livid borders. These were the 
principal cause of a violent itching, and indulgence in scratching gave 
rise to excoriation and chapping of the edges, with a discharge of sero- 
purulent fluid. A third variety were vividly red, indolent, and of 
small size, varying from that of the head of a pin to that of a small 
lentil. But these tumors bore no proportion to the sebaceous crusts. 
They were probably the consequence of irritation caused by the seba- 
ceous concretions, and can only be regarded as a complication of the 
sebaceous disease. 

As regards diagnosis, Dr. Jacobovics, after recapitulating the physi- 
cal characters of the preceding case, e.g., hereditary tubercles, varying 
in size from that of a lentil to that of a pigeon's egg (there were none 
so large in his case), round or irregular, usually sessile, brownish 
color, consistent or softish, generally solid, no constitutional disturb- 
ance, &c, remarks, "Among the tuberculous diseases of the skin, 
none but the present genus is capable of assuming the whole of these 
characters, so I am bound to establish this in the genus molluscum." 
An unfortunate preference for molluscum is already synonymous 
with heterogeneum. In the treatment of this case the author employed 
purgatives and warm baths, but with only partial success. 

I have lately met with a case in which the abdomen of a boy, par- 
ticularly its lower half, was in the state of sauriderma squamosum. 
The surface was covered with small, brownish, gray, convex squamae, 
of nearly uniform size and thickness. The scales were so regular in 
their arrangement as to give the idea of a normal rather than a morbid 
structure, and resembled very closely the scaly skin of some of the 
saurian reptiles. In other respects the skin was dry and harsh to the 
touch. When the squamae or crusts form upon the face, they occur, 
for the most part, in clusters, upon small patches of dry and congested 
skin ; sometimes they are met with on the sides of the nose, some- 

1 The masses are identical with those described at the commencement of this sec- 
tion. 



3 



568 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

times on the cheeks, and sometimes on the temples and forehead. In 
these latter situations, they are not uncommon in elderly persons, and 
are apt to give rise to alarm, from the supposition of their being of a 
cancerous nature. The latter notion is suggested from their being 
occasionally met with surmounting small patches of indurated skin. 
.When displaced from these patches of altered skin, the latter is apt to 
bleed, and not unfrequently a superficial abrasion of small size is found 
beneath the crusts. 

ICHTHYOSIS SEBACEA SPINOSA. 

Sauriderma spinosum. Porcupine disease. 

The spinous variety of ichthyosis is characterized by the formation 
of hardened masses of altered sebaceous substance, which acquire by 
growth the form, thickness, and length of short spines. This disease 
may be developed upon any part of the body, or upon the entire skin, 
with the exception of the palms of the hands and soles of the feet; the 
spots of election in the partial kind being the thick skin of the outer 
sides of the limbs, the convexities of joints, more particularly the 
elbows, wrists, and knees, and the dorsal surface of the trunk. Ichthy- 
osis spinosa is for the most part congenital ; it is associated with a dry 
skin, in which the perspiratory function is deficient; it is unaccom- 
panied by redness, heat, or local uneasiness, and it endures for a 
lengthened period, often for the lifetime of the patient. In the earlier 
periods of the disease the integument is unaffected, retaining its natu- 
ral softness and pliability ; at a later period, it becomes thickened and 
hard from infiltration and deposition, and the morbid action appears 
to extend deeply into the subjacent tissues. The spines are dense 
and hard, and for the most part of a dirty brown, or greenish brown 
color. 

The form and length of the spines in this disease are determined by 
certain laws, the former depending upon the shape of the small areae 
of the epidermis marked out by the furrows of the skin ; the latter 
upon the powers of the system, and consequent energy of secretion. 
In illustration of this view, it will be remarked that, of the spines 
produced upon the convexities of the elbows and knees, where the 
dermal areae are large and somewhat quadrilateral, the section has a 
similar form ; while, on the anterior aspect of the forearms, particu- 
larly near the joints, where the areae are narrow and elliptical, the 
spines are transversely flattened and slender. With regard to length, 
I have never seen any of the spines longer than a quarter of an inch; 
but Will an records instances in which they attained a full inch in 
some places. They stand out perpendicularly to the surface of the 
skin, their sides are polygonal, and when the limb is in its natural 
position, they fit closely side by side, so as to present, by their free 
extremities, an even and continuous surface. The free ends of the 
spines are more or less rounded and polished by attrition with the 
dress of the patient, and the sharp angles of their shafts are rounded 
off by friction against adjoining spines caused by the movements of 
the limbs. The base generally corresponds with the small area of 



DISEASES OF THE SEBIPAROUS ORGANS. 



569 



skin upon -which it is implanted, and to which it is firmly adherent ; 
but by degrees, as the activity of the secreting function subsides, the 
base becomes reduced to a slender pedicle, and is easily broken off. 

Examined with the microscope (Plate VI., fig. 5), the spines of 
ichthyosis are found to possess all the general features which might 
be expected a 'priori to be present in small cylinders of desiccated 
sebaceous substance; they are sub-fibrous, and obscurely laminated; 
the surface is more or less notched and jagged, the apex somewhat 
split, and the base frequently connected with a broad lamina of ex- 
foliated epidermis. Their internal structure is still more character- 
istic ; they generally contain, imbedded in their substance, several 
minute hairs, sometimes running in a serpentine manner through 
their entire length, but more frequently coiled and twisted, and 
evidently fixed in that position previously to their excretion by the 
sebiferous ducts. These observations lead to the inference, which I 
believe to be true, that the spines of ichthyosis are frequently, if not 
generally, formed upon the short hairs of the 
body as they issue from the skin; the hairs 
being naturally, and as a consequence, very 
much interfered with in their growth. 

This disease is not usually accompanied 
with constitutional symptoms ; the persons 
affected appearing to enjoy a moderate state 
of health. Sometimes irritation of the mucous 
membranes is coincident with the cutaneous 
affection ; and Willan has observed, that in- 
flammatory pustules or boils occasionally ap- 
pear on some part of the skin. The epider- 
mis of the palms of the hands and soles of the 
feet is dry and harsh, and there is frequent 
scaliness of the face. 

Willan has pointed out two appearances 
which the local forms of this disease some- 
times present, and distinguished them by the 
name of ichthyosis cornea. In one of these 
the spines are curved or twisted, and unusually 
long, and suggest the idea of miniature ram's 
horns. In the other the spine is broad and 

single, and constitutes a hornlike mass. These peculiarities are rare, 
and no purpose is gained by their separation from the typical disorder. 

Diagnosis. — Cazenave and Schedel, who refer to Biett's descrip- 
tion of this affection, state that, when it has appeared upon the nose, 
it has been mistaken for noli me tangere. This error I have seen 
committed; but it is not one likely to be fallen into by those who 
examine the scale-like masses with attention. The presence of dense 
scales or spines, and the irregularity of position and form sufficiently 
distinguish ichthyosis sebacea from every other disease of the skin. 

Causes. — This affection occurs at all ages; ('specially in persons of 
phlegmatic temperament, in whom the skin is thin and delicate. It 
is sometimes accompanied by an unctuous state of the integument, 




A spine from a "porcupine 
boy." The spine is magnified 
19 times. It contains in its 
structure a group of downy 
hairs, which form convoluted 
bunches here and there. 



3 



570 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

but more frequently by a dry and parched condition of the epidermis, 
and shrivelled appearance of the skin. Occasionally it has been seen 
after parturition. The most frequent cause I believe to be torpor of 
the skin and absence of proper excitation by ablution and friction. 

Ichthyosis spinosa is for the most part hereditary, appearing in the 
male branches of a family only, as in the instance of the Lamberts, 
but often originating without any similar disease having been known 
to exist in the family of the diseased person. In rare instances it 
appears a few days after birth, but more frequently shows itself for 
the first time at the end of two or three months. Rayer alludes to a 
foetal monster preserved in the Anatomical Museum of Berlin, the 
whole surface of whose body is covered by a layer several lines in 
thickness, which, being broken up into small pieces, gives it the ap- 
pearance of a coat of mail. When the disease occurs after puberty, 
or in the adult, it would appear to be dependent on local and endemic 
causes. Among these have been enumerated, the ingestion of bad 
fish, bad water, humidity of atmosphere, &c. Buffon states the dis- 
ease to be endemic in Paraguay ; and several places on the sea-coast 
have, equally incorrectly, obtained a similar reputation. 

Treatment. — The first indication presented to the mind, in con- 
sidering the nature of ichthyosis sebacea squamosa with reference to 
treatment, is to remove the scaly concretion ; and the second to excite 
the sebiparous glands to healthy action. The former object is to be 
effected by means of the warm bath, or warm alkaline fomentation, or 
by water-dressing. The second may be attained by frequent ablutions 
with warm or cold water, succeeded by brisk frictions with a rough 
towel ; sea-bathing, and astringent lotions. The bichloride of mer- 
cury in emulsion of bitter almonds is a useful application in this 
affection ; so also is the lapis divinus, in the form of lotion or oint- 
ment. During the progress of the local treatment, it will be desirable 
to administer some laxative medicine, and to regulate the diet of the 
patient. 

In ichthyosis sebacea spinosa the spines are to be softened by warm 
alkaline ablutions or baths, or water-dressing, and then some stimu- 
lating application made to the skin; such as a lotion containing a 
drachm of tincture of croton to the half-pint, or a liniment containing 
a small quantity of liquor ammonise. Constitutional remedies, such 
as the symptoms may indicate, are to be used internally, as alteratives 
and tonics; and Fowler's and Donovan's solution will be found valu- 
able as determining an increased action and improved condition of 
the skin. The liquor potassse, with decoction of sarsaparilla, may also 
be tried with expectation of relief. Willan, Bateman, and Elliotson 
have recommended pitch, in doses of an ounce daily. 

IV. RETENTION OF SECRETION. 

The present group of diseases of the sebiparous glands is charac- 
terized by distension of their ducts and related hair-follicles, with 
more or less alteration in the quality of the secretion, the alteration 
tending chiefly to inspissation. This group admits of division into 



DISEASES OF THE SEBIPAEOUS ORGANS. 571 

two sub-groups or families, in one of which the excretory hair-follicle 
still remains open, the secretion is inspissated, and in communication 
with the exterior. In the second family the excretory hair-follicle is 
closed at its aperture, and the escape of the secretion prevented. 

(a.) Retention of secretion in the sebiferous ducts, the excretory 
aperture remaining open. 

COMEDONES. 

Syn. Gf-rubs. Worms. Mitesser, Germ. 

The simplest form of this disease is that which is popularly known 
under the name of worms or grubs. In this affection, the sebaceous 
secretion is inspissated, and produces complete distension of the re- 
lated hair-follicle. Reaching the mouth of the latter, the secretion 
hardens, and becomes deeper in color; and at the same time, from 
being exposed to the dust and dirt of the atmosphere, the extremity 
is rendered dingy and dark-colored. This discoloration of the seba- 
ceous substance at its extremity gives rise to the appearance of a 
round black spot, with which, in some persons, the skin of the face, 
particularly of the nose, is more or less thickly studded. If a fold of 
skin, including one of these spots, be pressed between the fingers, the 
concreted secretion is squeezed out, under the form of a little white 
cylinder, about a line in length, and blackened at its extremity. It 
is the lengthened form of this little cylinder, with its dark extremity, 
that has gained for it its popular designation. 

Instead of being soft and easily pressed out from the hair-follicle, 
it sometimes happens, where the secretion has remained undisturbed 
for some time, that the little cylinder has become desiccated, and re- 
sembles horn, both in appearance and density. In this case the con- 
cretion requires to be dislodged by a pointed instrument, or with- 
drawn by means of a pair of ciliary forceps. In an instance of the 
kind now before me, there are several patches of skin, of about the 
size of a crown-piece, on different parts of the body, closely studded 
with these horny comedones, every hair-follicle in the affected area 
being occupied by its little spine, slightly projecting beyond the plane 
of the surrounding skin. 

The disorder of the sebaceous glands here described is commonly 
met with on the face of persons in whom the cutaneous circulation is 
less active than natural, and particularly among the inhabitants of 
cities and large towns, in whom the brain and nervous system claim 
an undue proportion of the vital energies ; and in whom congestions 
of the viscera are not unfrequcnt. It is generally associated with the 
presence of other diseases of the sebiparous glands, and is always met 
with in combination with acne. Indeed, one form of acne, acne punc- 
tata, is simply an inflammation of the sebiparous gland and related 
hair-follicle, excited by the overload of inspissated secretion. 

When the substance expressed from one of these comedones is 
examined with the microscope, the sebaceous mass is found to be 
altered in its composition. Instead of flattened epidermal cells or 



572 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

scales, intermingled with myriads of oil-globules, which compose the 
normal secretion, the inspissated substance consists of cells containing 
a granular substance, and a variable number of oil-globules. Besides 
these cells, several minute hairs are seen in the centre of the mass; 
they are usually twisted, or bent, and sometimes to such an extent 
that the tapering point is approximated to the root. Occasionally I 
have observed the epidermal follicle still surrounding one of the hairs, 
and more frequently so when one only exists in the sebaceous mass. 
In this case the bulb of the hair is perfect ; its fibrous brush-like root, 
and the granular mass of the pulp, are distinctly apparent. More fre- 
quently, the hairs are broken at their larger ends, and the fibrous 
structure of the hair is evident. The number of hairs seen in the 
mass of a comedo appears to have relation to the period of impaction 
of the sebaceous substance ; for when the matter is soft, and of recent 
collection, I have found only one hair, or at most two, one of the two 
being surrounded by its epidermal follicle; but when the mass has 
been impacted for some time, I have counted upwards of twenty. 
(Plate III., fig. 18.) Dr. Gustav Simon remarks, that he has seen as 
many as forty in some comedones. 1 

This observation is an illustration of the physiology of the invisible 
downy hairs of the body, and serves to prove that which, a 'priori, we 
should be led to infer, and indeed that which their presence in the 
ceruminous substance of the meatus auditorius in such numbers also 
testifies, namely, that they are continually thrown off, after attaining 
a certain length, and continually reproduced. In the instance"before 
us, the pathology of the comedones, the sebaceous secretion is poured 
as usual into the hair-follicle, but instead of being excreted from 
thence, and diffused upon the skin, collects, probably as a consequence 
of its altered nature, and obstructs the follicle. The little hair, when 
thrown off by the usual process, is no longer conveyed away from the 
follicle with the sebaceous secretion, but is surrounded by the latter 
in its altered state, and remains enveloped in its substance. By a 
continuance of this process, a number of hairs may thus be amassed. 

Dr. Gustav Simon has recently discovered, in the sebaceous sub- 
stance of comedones, and in that which is squeezed out from the cones 
of acne punctata, certain microscopic animalcules, supposed, by the 
entomologists of Berlin, to be related to the genus acarus ; hence, Dr. 
Simon terms the animalcule acarus folliculorum. A description of this 
animalcule will be found in a separate chapter, at the conclusion of 
the volume. 

Treatment. — The treatment of comedones requires the employ- 
ment of such means as are calculated to stimulate the skin gently, and 
excite it to the due performance of its proper functions. The parts 
affected should be saturated with soap, and thoroughly washed ; they 
should then be rubbed briskly with a rough towel, until the skin be 
felt to glow; and this should be repeated twice in the day. The 
immediate effect of this treatment may possibly be a red and patchy 
state of the skin, which will speedily pass away. It would be well in 

1 Muller's Archiv., No. 2, 1842. 



DISEASES OF THE SEBIPAROUS ORGANS. 573 

these cases to extend the ablutions and frictions to the entire body, for 
the appearance of the disease in one part is indicative of a generally 
torpid action of the skin. Cold bathing and sea-bathing are also cal- 
culated to be beneficial. In some instances it may be necessary to 
employ some medicinal stimulant, in which case the bichloride of mer- 
cury lotion with spirits of wine, or with the emulsion of bitter almonds, 
will be found to be the best application. 

ACCUMULATIONES SEBACEAE. 
MOLLUSCUM SIMPLEX. 

Syn. Small sebiparous tumors, Wilson. Molluscum contagiosum, Bate- 
man. Molluscum sessile; subglobulosum ; parvum ; pisiforme. 

In a second group the secretion is not confined to the excretory 
duct, but distends also the primary ramifications of that duct, so as to 
give rise to a small tumor, about equal in size, in its fully developed 
state, to a ripe currant. (Plate VI., figs. 6, 7, 8.) This resemblance 
is not confined to size alone, for the sebaceous substance, rising to the 
aperture of the follicle in the centre of the tumor, appears like the 
depression on the summit of the currant to which the corolla is 
attached, while the sebiferous ducts swell out in the circumference of 
the tumor, and give it a slightly lobulated appearance. When a 
transverse section of this little tumor is made, it is found to be divided 
into five or six segments, each of the segments containing a dilated 
branch of the excretory duct. The swelling of these segments, more- 
over, gives rise to a depression on the summit of the tumor, corres- 
ponding with the aperture of the duct, from which a portion of the 
concreted sebaceous substance can always be removed by means of a 
pointed instrument, and it also produces a constriction around the base 
of the tumor. 

When these little tumors are left to themselves, they terminate, 
according to my observation, in one of two ways: either by ulcera- 
tion of the summit, and discharge of the sebaceous substance and 
gland en masse, for the gland is but loosely connected with the integu- 
ment; or by inflammation and sloughing of the entire tumor. In the 
former case, the collapsed integument, when the base of the tumor has 
become much constricted, forms a small, pendulous, pyriform append- 
age, verruca acrochordon, which remains for the rest of life. In the 
latter, the ulceration sometimes extends deeply into the skin, and 
leaves behind permanent and unsightly cicatrices. 

An instance of this disease lately (March, 1842) presented itself to 
ray notice, which was remarkable for the active development of the 
tumors. They were first perceived, about fifteen or twenty in number, 
dispersed upon the skin of the neck, face, and shoulders of a little 
girl, four years of age. By the advice of the family medical attend- 
ant, she was sent into the country, and in the course of a few weeks 
became quite well, all the tumors having disappeared, and no new 
ones being formed. Soon after her return to town, the mother brought 
to me her two other children, an infant and a girl of six years old. The 



574 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

mother and children were of fair complexion, with light hair, and 
thin delicate skin; the mother was alarmed at the development of 
these little tumors on her two other children as well as on herself, 
" caught," as she imagined, from the child first affected. I quieted her 
alarms relative to contagion, but was much struck by the fact of the 
almost simultaneous appearance of the disease upon four members of 
the same family. On the neck of the mother I found four or five of 
these little tumors closely resembling and of the size of currants, 
constricted at their base, and each presenting an umbilicated depres- 
sion of impacted sebaceous substance, the aperture of the excretory 
follicle ; and she directed my attention to three ugly scars upon the 
face left by similar tumors recently healed. On the neck, face, and 
shoulder of the eldest child I found eight or ten little tumors, pre- 
senting all their stages of growth. One upon the shoulder was so 
completely pedunculated, that 1 was tempted to place a ligature around 
it, and in a few days it fell off. On the infant they were less advanced, 
they were just rising from the integument, and each possessed in its 
centre the dark point of an excretory sebiferous follicle. The little 
tumors presented no signs of inflammation, they were of the natural 
hue, or somewhat lighter than the surrounding skin, from the white- 
ness of the secretion which they contained, and there was no areolar 
redness round their base. 1 

Since the above account was written I have again (August, 1842) 
been visited by this patient, on account of the development of a small 
angry tumor of a similar kind on the margin of the upper eyelid of 
her little girl, involving two or three of the Meibomian glands. With 
this exception the children have remained free from any return of the 
tumors. On inquiry as to the manner in which they disappeared, the 
mother tells me that they became black, and shortly after were rubbed 
off accidentally. One of large size, and situated behind the ear, in the 
child first affected, was snipped off by Mr. Tyrrell. The mother, who 
is out of health, has three still remaining, one of small size near the 
angle of the right eye, and two upon the back of the hand. 

Upon examining these little tumors I found them to present all the 
characters of a small conglomerate gland, 2 consisting of several lobules 
held together by cellular tissue, and the lobules composed of ramified 
ducts and terminal sacculi. The ducts were remarkably dilated, par- 
ticularly the central one, and were filled with inspissated secretion. 
The latter was identical in composition with the concreted sebaceous 
substance of the comedones. The cells were of the same size, had the 
same appearance, and were intermingled in considerable number with 
epidermal scales. I disagree with Dr. Paterson in considering these 
cells as peculiar organisms, capable of nucleolar propagation when 
transferred to an appropriate nidus in another individual, and simply 
regard them as the normal sebaceous cell, which contains a granular 
substance, filling it more or less completely. 

1 For an illustration of this disease, see "Portraits of Diseases of the Skin," Plate 
XXXVIII., AF. 

2 This observation confirms the description given by Dr. Henderson. 



DISEASES OF THE SEBIPAROUS ORGANS. 575 

The difference in the appearance of the cells examined by Dr. Pa- 
terson and by myself appears to me to be immediately explained by 
reference to the physical difference in the contents of the tumors. In 
Dr. Paterson's case the contents, as in Bateman's, were milky, and 
consequently semi-fluid; and the conditions were favorable to the 
production of cells, having a considerable interval filled with fluid 
between the granulous nucleolar substance and the membrane of the 
cell, a disposition which induced Dr. Paterson to regard them as being 
composed of an external vesicle and an internal vesicle, the latter con- 
taining the granular substance. But, in my cases, the contained sub- 
stance was concreted, there was a deficiency of fluid, and the granu- 
lous substance filled the cell, and in exceptional cases only were any 
cells perceived with a peripheral interval. On the second day, when 
the mass had been steeped in weak spirit for a number of hours, the 
peripheral interval was evident in a considerable number. 

On examining my new stock of sebaceous matter (August, 1842), 
fresh from the patient, I found it to consist of cells heaped together 
like a pile of eggs, and intermingled with a large quantity of epidermal 
scales in flakes. The mass consisted solely of these two substances, 
without any granular matter or oil-globules. The cells were variable 
in figure, some being more or less cuboid, others irregular from com- 
pression, some oblong like the eggs of the ant, others oval, but the most 
common form wast>void, like that delineated in the figures of Dr. Hen- 
derson and Dr. Paterson. The cells presented equal diversity in size, 
varying in their long diameter from ? i ? to 5 ^ 7 of an inch, and in their 
short diameter from j^n *° tttt 5 some of the cuboid cells measured 
i-Q-Q-Q ; the general size of the oval form was g ^ l° n g> an d tou o b roa d ; 
there were several oblong cells, measuring gig by y^ 1 ^; and the com- 
mon dimensions of the ovoid cell were 7 £ n by T ^^. This size corres- 
ponds very closely with the cells of ordinary inspissated sebaceous 
substance, whether it be concreted or pulpy ; and also with the dimen- 
sions of the epidermal- scales lying scattered among the cells. The 
contents of the cells were also various ; some were filled with granular 
substance, in the midst of which, at some one point, a nucleus was 
perceptible ; others contained a homogeneous substance, separated 
into polygonal masses, mostly of a cuboid shape ; while others, again, 
were more or less filled with minute oil-globules. It is difficult to say 
which kind of cells were most numerous. I saw nothing like the 
double vesicle described by Dr. Paterson, and I think it possible that 
the appearance which he has delineated may have been produced either 
in the manner I have already suggested, or by the superposition of a 
single cell by several connected scales of epidermis; or again, by the 
accidental posit ion of the cell upon the epidermal scales in such a man- 
ner as to constitute a thin margin around it. 

Tkkatment. — In the case above detailed I prescribed laxative 
medicine, and touched the -tumors with nitrate of silver several 
times. By this treatment I succeeded very speedily in removing them. 
1 have mentioned that a ligature was placed around one; a more ex- 
peditious mode of getting rid of them would be to snip them off with 
scissors. In adults they may always be snipped off. On the mother 



576 DISEASES OP SPECIAL STRUCTURE OF THE SKIN. 

of these children I opened several with a lancet, and touched them 
inside with nitrate of silver. Their return may be prevented by the 
plan of stimulation of the skin, recommended for the treatment of come- 
dones. Dr. Thomson used sulphate of copper, and Dr. Paterson 
potassa fusa, in their treatment. In a case which I lately saw under 
treatment in the wards of St. Louis, M. Lemery employed nitric acid. 

In the'mode of cure of these tumors I perceive another argument 
against their contagious nature. They disappeared in the first child, 
on the recovery of her health, during a short visit to the country, 
without local treatment. In the case of the other two children many 
of the little tumors fell off, and the disease got well under the use of 
the compound senna powder. The three at present on the skin of the 
mother are attributable to a disordered state of health. Indeed, the 
family may be said to be the subject of a sebaceous constitution, and 
any recurrence of disordered health will bring with it a disposition to 
the formation of sebaceous tumors. 

After having determined the nature of the small tumors above 
described, and having assigned to them the position which they appeared 
entitled to occupy among diseases of the skin, I read, for the first time, 
with attention, the cases narrated by Bateman, under the head of 
Molluscum, and was struck with the identity of Bateman's cases with 
those I had just witnessed. Pursuing my inquiry with a view to ascer- 
tain the true meaning of the term, and that which seemed to be in- 
tended in its original application, I came to the conclusion expressed 
by Dr. Jacobovics, 1 that Bateman must have borrowed the appellation 
from the essay of Dr. Ludwig, 2 the reporter of the celebrated case 
which occurred to Tilesius. The author in his preface remarks, " Rhein- 
hardi, visu foedum, corpus tectum est verrucis mollibus sive molluscis." 
Alibert, Biett, Cazenave, and Schedel, on the contrary, attribute the 
origin of the term to some resemblance existing between the cutane- 
ous tumors and the knots on the bark of the maple. 

The earliest case of this affection on record, and the one in fact 
which, according to the above supposition, gave the designation to the 
disease, is that of Tilesius, recorded by Ludwig. I propose to make 
an analysis of this case, as well as of those which have been published 
on the same subject to the present time, in order to ascertain the 
opinions entertained by their respective authors of the cases which 
have appeared in their names. The result of this inquiry will be a 
confirmation of my opinion respecting the pathology and true position 
of molluscum. 

Case observed by Tilesius. — John Godfrey Reinhardt was born at 
Muhlberg, of healthy parents, in 1742. At birth, his body was covered 
with excrescences of small size. When seen by Tilesius in his fiftieth 
year, these excrescences varied in size from that of a pea to a pigeon's 
egg. Their form was various, some being like warts, others oval, 
others irregular, and others flattened, -either by the clothes of the 

1 Du Molluscum, recherches critiques, &c. Paris, 1840. 

2 Hisloria pnthologica singularis cutis turpitudinis J. G. Rheinhardi viri 50 annorum, 
&c. By Dr. C. F. Ludwig. Lipsige, 1739. 



DISEASES OF THE SEBIPAROUS ORGANS. 577 

patient or by pressure against an adjoining part. The most remarka- 
ble of these excrescences was one which was developed from the inte- 
gument over the ensiform cartilage ; it was wallet-shaped, tuberculated 
on the surface, flaccid, and hung as low as the umbilicus. Its tuber- 
culated appearance indicates its constitution of several smaller excres- 
cences. The prevailing color of the tumors is red ; here and there 
one may be seen of a dull yellow or reddish brown hue ;' they are 
spongy and soft in texture, and the skin which supports them is dirty- 
looking and earthy. " In medio quarundum maximarum excrescentia- 
rum parvum foramen conspicitur, ex quo nigra corpora oblonga, quae 
altius in cute albicantem atque tenerum processum habent, exprimi pos- 
sunt, quaz vulgo comedones appellantur." 

The excrescences are most numerous by the side of the vertebral 
column, on the thorax, neck, and the sides of the abdomen. On the 
head, one has the appearance of an encysted tumor. Regularly every 
month some of the tumors become congested, and itch greatly, 
forcing the patient to scratch them violently. He is the subject of 
habitual feverishness, which is increased at each fresh attack of con- 
gestion of the tumors, and is accompanied by loss of appetite. 

Reinhardt is short of stature, has a large head, knees somewhat 
incurvated, protuberant abdomen, and dull expression of countenance. 
His position in life is one of indigence and misery. He has invaria- 
bly refused to permit the removal or puncture of one of the tumors, 
so that their internal structure is entirely unknown. 

Such is the case observed by Tilesius. The question now comes to 
be, What is the nature of the disease ? Let us review the evidence. 
An unhealthy child, born with disordered sebiparous glands, the 
ducts of the glands loaded with inspissated secretion, and forming small 
prominences on the surface of the skin. The child bred in " indi- 
gence and misery ;" the skin "dirt-colored, and earthy in appearance ;" 
the child and man unsound in body, sluggish in functions. Here, 
then, are precisely the conditions which we should desire to bring 
together for the purpose of inducing the disease artificially. For the 
IB081 conclusive of all evidence, mark the Latin passage quoted from 
the original ; the excretory aperture in the centre of the largest 
tumors, the altered sebaceous substance squeezed out, nay more, its 
comparison with "comedones." One of the tumors situated rn the 
scalp we find to have taken on the usual characters of a sebaceous 
encysted tumor. The sebaceous tumors in this case are remarkable 
for being the largest on record. But why ? Because they were 
reared in excellent soil, and because they possessed a growth of half a 
century. One assumes the form of a wallet, but this we find is the 
aggregation of several, growing from a limited spot of skin and one 
richly supplied with sebiparous glands. The wallet is also favored in 
its growth by the constant irritation produced by the pressure of the 
Bhoemaker's last. The constitutional symptoms form no part of the 
disease, only so far that such an abundance of unhealthy glands 
would necessarily excite general disturbance, and, aided by "indigence 
and misery," and by endemic conditions, would conduce to the 

37 



578 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

development of intermittent fever, under which the patient suffered 
several times. 

One other observation is elicited by this case, namely, that no 
suspicion of contagion appears to have occurred to the minds of any 
of the persons named in the narrative. The father and mother of the 
patient never suffered from a cutaneous complaint ; his two brothers 
were free ; his two wives were equally exempt, together with an 
infant child. But this is the typical case of molluscum, with which 
all future observations must be compared ; this is the case which has 
supplied dermatologists with their definition of the disease, which 
enabled Bateman to announce that molluscum " is characterized by 
the appearance of numerous tubercles, of slow growth and little 
sensibility, and of various sizes, from that of a vetch to that of a 
pigeon's egg. These contain an atheromatous matter, and are of 
various forms ; some being sessile, globular, or fiattish, and some 
attached by a neck, and pendulous." 

None of the tumors were punctured in Reinhardt's case, but that 
omission is of little moment, when we again advert to the Latin 
quotation. The tumors from which no sebaceous substance escaped, 
upon which no aperture was apparent, were undoubted instances in 
which the excretory aperture had closed, as in encysted tumors. 

Cases observed by Bateman. — This author reports six cases of sebi- 
parous tumors which he considers, in reference to the case of Tilesius, 
"a singular species of molluscum." In my opinion, the only differ- 
ence between Bateman's cases and that of Tilesius is one of duration ; 
and the same observation applies to all the cases recorded since his 
time. The sebaceous tumors of Reinhardt were of fifty years' growth. 
The assumption of the contagion of these cases appears to me as 
unfounded as in the four cases I have myself related. It will be 
remarked, that of Bateman's seven cases, three were children of the 
same family ; two were children, apparently, of another family ; and 
two were servants in the first family — one an undoubted case, the 
other supposititious. But to proceed : 

" The face and neck of this young woman," writes Bateman, "were 
thickly studded with round, prominent tubercles, of various sizes, from 
that of a large pin's head to that of a small bean, which were hard, 
smooth, and shining on their surface, with a slight degree of transpa- 
rency, and nearly of the color of the skin. The tubercles were all ses- 
sile, upon a contracted base, without any peduncle. From the larger 
ones a small quantity of milk-like fluid issued, on pressure, from a 
minute aperture, such as might be made by a needle's point, and 
which only became visible on the exit of the fluid. The progress of 
their growth was very slow ; for the first tubercle had appeared on 
the chin a twelvemonth ago, and only a few of them had obtained a 
large size." " She ascribed the origin of this disease to contact with 
the face of a child, whom she nursed, on which a large tubercle of the 
some sort existed ; and on a subsequent visit she informed me that two 
other children of the same family were disfigured by similar tubercles ; 
and, besides, that the parents believed that the first child had received 
the eruption from a servant, on whose face it was observed. Since 



DISEASES OF THE SEBIPAROUS ORGANS. 579 

my attention was drawn to this species of tubercle, I have seen it in 
another instance, in an infant brought to me with porrigo larvalis ; 
and, on investigation, it was found that she had apparently received 
it from an older child, who was in the habit of nursing it. In this 
case the milky fluid issued from the tubercles, and may be presumed 
to be the medium of contagion." 

Cases observed by Br. John Thomson and Dr. Carswell. 1 — The first 
case occurred in the Canongate, in April, 1821, in three children of 
the same family. The eldest boy was supposed to have brought the 
disease from school, and to have transmitted it to his brother and 
sister. " The contagious nature of the disease is well evinced in the 
child. On the back of its hands a considerable number of tubercles 
are seen, which have been produced by applying them to the face, and 
scratching those situated there during their inflammatory stage. Some 
of the tubercles are small, others large ; some in a state of active in- 
flammation, others nearly of the same color as the skin, and quite free 
from pain. A few of them are pedunculated, but the greater number 
are attached by broad bases." " The mother, though in the constant 
habit of nursing the youngest child, has not been infected." 

A second series of cases came more recently under Dr. Thomson's 
attention. A farmer's child was affected with the characteristic little 
tumors : he had taken the contagion from the child of a farm-servant. 
Some of the tumors were situated on the eyelids, and gave rise to con- 
junctivitis. While suffering from this disease, the child rested his face 
against the neck of a servant girl as she tended him, and she, too, 
became the subject of sebaceous tumors. 

These cases are narrated in the true spirit of contagion, and with an 
unconditional assent to the opinions of Bateman. I regret that less 
attention was bestowed in ascertaining the state of the skin and sebi- 
parous system of the patients, their health, and especially their habits 
of cleanliness. 

Case observed by AUbert. — Alibert treats of the molluscum of Bate- 
man, under the name of mycosis fungoides, and he associates the dis- 
ease with the Amboyna and Molucca pox, with which it bears con- 
siderable analogy. His definition is brief, but vague. He observes : 
"The disease appears upon one or several parts of the body, in the 
form of fungoid (fongueuses?) and oval-shaped tumors, which arise and 
arc developed successively upon the face, upper and lower extremities. 
Tli esc tumors, which are very analogous in texture with champignons, 
after having reached their full growth, open like decomposing fruits, 
and give exit to an ichorous fluid, which is often puriform, and sheds 
around it a disgusting odor." 

The case from which he derives his definition I will shortly narrate. 
The mother of the patient had upon the face an ulcer that was cured 
by the application of caustic ; his brother died of a cutaneous disease, 
which resisted all medical treatment. The man, named Lucas, was 
fifty-six years of age; his disease was ushered in by a furfuraceous 
eruption, which was soon after succeeded by the development of small 

1 Edinburgh Medical and Surgical Journal, vol. Ivi. p. 280. Dr. Paterson's paper. 



580 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

tubercles, smooth and polished on their exterior, and presenting, for 
the most part, the ordinary hue of the skin, some few having a brown- 
ish tint. They were distributed over nearly all parts of the body. 
They resembled morelles or agarics in form ; some were shaped like 
an olive ; and they increased in number to such an extent that four- 
teen were removed from the face. Their base was large ; they were 
spongy in texture, and they exuded a reddish fluid, which imparted a 
greenish or yellowish stain to his linen. This fluid concreted on the 
tumors into the form of a brownish or grayish crust. The majority 
of the tumors terminated by bursting, and then falling into a flaccid 
state, leaving in their place a withered skin, which the daughter of the 
patient removed with scissors, without exciting pain. After experi- 
encing considerable mental affliction, he had an attack of pemphigus. 
The tubercular disease increased rapidly after this period ; the tuber- 
cles, on breaking up, gave rise to ulcers, the patient suffering from 
lancinating pains in these ulcers ; he became emaciated and hectic, and 
died, after keeping his bed for seven months, and being the subject of 
this disease for five years. 

This case is not satisfactory : the seat of the disease in the sebi- 
parous glands is not proved ; indeed, Alibert suggests no opinion with 
regard to the pathology of the tumors, but contents himself with classi- 
fying them with the molluscum of Bateman. Examination after 
death Avas unfortunately refused : had that been made, I have no doubt 
that serious visceral disease would have been discovered. I think it 
very unlikely that the man died of the cutaneous disease. 

Rayer, who had never seen a case of this disease, remarks with 
regard to it, that its " seat appears to be the sebaceous follicles." 

Cases observed by Biett. — Biett, in the Dictionnaire de Medeeine, 
referring to the case of Tilesius, remarks, that he had seen two 
analogous cases, but that in these the tumors were hard and con- 
sistent, and contained neither atheromatous matter 1 nor liquid. He 
also cites the instance of an old man, whose skin was covered with 
these little tumors, without any disturbance of his health. Biett met 
with another form, "non-contagious molluscum," in young women 
after parturition. In these cases the little tumors were flattened, 
slightly fissured (fendillees) at their summit, irregular in form, and 
brownish or fawn-colored in tint. They were indolent, and more par- 
ticularly distributed about the neck. 

Such is the evidence of the distinguished Biett ; but, with all 
deference to his judgment, I see in these cases no reason for altering 
my opinion with regard to the pathology of the tumors. Nor can I 
perceive any difference between the two forms of non-contagious 
molluscum, which he seems desirous of establishing. 

1 By the term "atheromatous matter" is to be understood sebaceous substance altered 
to the appearance and consistence of pap. The word "liquid" no doubt relates 
to the '-milky fluid" of Bateman. There was no such fluid in my cases; the sebaceous 
substance was concreted and dense ; not soft, as in the case of Tilesius, nor fluid, 
as in those of Bateman. Biett's appear to have been similar to mine. Since the 
publication of my first edition, I have repeatedly seen the milky fluid described by 
Bateman. 



DISEASES OF THE SBBIPAEOUS ORGANS. 581 

Cases observed by Cazenave and Schedel. — These authors relate that 
they saw, in the Hospital St. Louis, a patient affected with prurigo, 
on whose body were a number of little indolent tumors. The largest 
were scarcely so large as a hazel-nut, others were no larger than a 
small pea. They appeared formed of a dense fibrous substance, and 
pressure produced no pain. After describing "molluscum non con- 
tagiosum," they continue, " Molluscum contagiosum is a very rare 
disease, and does not appear as yet (1828) to have been observed in 
France. It is characterized by tubercles, rounded, prominent, hard, 
different in size, smooth, transparent, sessile, giving exit by their 
summit to a white fluid," &c. 

Gases observed by Gribert. — This author does not conceive it necessary, 
in his treatise, to describe molluscum, of which he remarks that he 
has seen but two or three undoubted cases in the course of fifteen 
years. One of these occurred in the service of M. Biett, in a child 
ten years of age, afflicted with chronic enlargement of the liver 
and spleen, the consequence of a fall on the abdomen. The entire 
skin was sprinkled over with small whitish tumors, of about the size 
of peas. They were hard, indolent, and not unlike those little 
cretaceous tumors we occasionally meet with in the substance of the 
liver. M. Biett considered that the disease should be referred to the 
genus molluscum of Bateman, a rare affection in our climate, but not 
unfrequent in India. 

Cases observed by Br. Jacobovics. — In the spring of 1839, this author 
saw, at St. Louis, two women, one sixty, the other seventy years of 
age, who were covered with fungiform tubercles. To describe these 
tubercles would be to repeat the observation of Tilesius. The face, 
neck, head, and limbs, were closely set with the morbid excrescences ; 
at the base of the right hypochondrium of one patient, and on the neck 
of the other, one of these tumors was as large as the fist, and shaped 
like a wallet. The tubercles were red in color, and the greater part 
poured out a small quantity of ill-smelling sero-purulent fluid, which 
every here and there concreted into thin crusts. No other member of 
the families of these two women had suffered from a similar disease, 
and on one the eruption had existed for two years. These cases were 
not further observed. 

In his essay on molluscum, Dr. Jacobovics attempts the classifica- 
tion of all the known diseases possessing the general characters of 
those of Tilesius and Bateman, as three varieties of the genus mol- 
luscum. In this attempt he has signally failed ; he has succeeded 
only in bringing together the most heterogeneous materials, under an 
unmeaning title, a title that would be far better abolished altogether 
from cutaneous pathology. His three proposed varieties are tubercula 
fongosa, tubercula atheromatosa, and tubercula variegata. Under the 
first of these, which, to illustrate his meaning, should have been /tm- 
gtformia, he has assembled the Amboyna pox, the cases of Tilesius 
and Alibert, the cancer mollusciforme ! of Rayer, the cases of Biett, 
Cazenave, Schedel, and Gibert, and the molluscum pendulum of Wil- 
lan. Under the second variety, he groups those cases which have 
been assumed to be contagious, namely, those of Bateman and 



582 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

Thomson ; and he reserves the third designation for his new variety, 
the " tubercules bigarres," which I have already transferred to a more 
appropriate place, namely, the section treating of sebaceous ichthyosis. 

Cases observed by Br. Henderson. 1 — Dr. Henderson has seen five cases 
of this disease identical in their characters with those which fell under 
my notice, and closely corresponding with those of Bateman. They 
all occurred in the children of poor persons ; and the finest case was 
that of an orphan boy, eight years of age, an inmate of a workhouse. 
Relative to contagion Dr. Henderson speaks with caution. Three of 
the children were members of the same family ; one was a neighbor's 
child ; the remaining one, the orphan child, was an isolated case. 
The children who exhibited the molluscum in the most marked 
degree, were very unhealthy, having a tumid abdomen and tubercular 
deposits. The two youngest, twins, died of acute hydrocephalus, the 
orphan boy of peritonitis and other serious disease. One of the twins 
had only two tubercles, the other twelve on the face and one on the 
ankle ; the two other children had only one each, but in the orphan 
boy there -were considerable numbers. They were principally situ- 
ated on the lower part of the abdomen, the organs of generation, and 
the inner sides of the thighs ; in these regions there were three or 
four dozen ; on the right arm there were four, on the left ten. They 
varied in size, from a millet-seed to a pea ; they were, for the most 
part, rounded in form, constricted around the base, and had each a 
small dark-colored central point, from which might be squeezed a 
little milky fluid. On the back was an elliptical swelling of large 
size, measuring one inch and a half in its long diameter, and one inch 
and a quarter across. In the centre of this swelling was a small 
elevation, a kind of crater, and at the apex of the latter an excretory 
opening, through which might be squeezed a quantity of soft white 
substance resembling finely-ground rice, boiled. 

Examining the structure of these little tumors, Dr. Henderson 
found them to consist of vertical cells opening towards the centre, and 
discharging their contents into a common cavity, which communicated 
with the exterior by the excretory opening. The large tumor was 
lobulated in structure, and upon its under surface had the " general 
appearance of a conglomerate gland;" it illustrated, on a "larger 
scale, the conformation of the smaller ones." The contained matter 
of these tumors consisted of nucleated cells, which, according to Dr. 
Paterson, were about the j^^ of an inch in diameter. Dr. Hender- 
son inoculated with some of this matter, but without producing any 
result ; and he remarks, very justly, that if the disease be considered 
to be an affection of the sebiparous glands alone, the inoculated sub- 
stance would not be likely to take effect, unless it were brought in 
contact with the internal surface of a sebiferous duct. 2 Some excellent 
figures accompany this paper ; numbers 1 and 5 are admirable for 
their truthfulness. 

1 Edinburgh Medical and Surgical Journal, vol. Ivi., 1841, p. 213. 

2 A more effectual mode of inoculation would be to rub the secretion briskly into 
the skin in a situation where sebiparous glands are abundant. 



DISEASES OF THE SEBIPAEOUS ORGANS. 583 

Cases observed by Dr. Pater son} — This physician records five cases 
of molluscum contagiosmn. The first he saw in a child eighteen 
months old, robust and healthy, and the daughter of cleanly parents, 
the father being a fisherman. The little tumors had the pathogno- 
monic form, the constricted base, the central aperture, and the oozing 
of milky fluid. They varied in size from that of a pin's head to that 
of a horse-bean, the smaller ones resembling " pearly granulations" 
(sebaceous miliary tubercles). They were seated chiefly on the face 
and neck, and were not painful on being touched. After the appear- 
ance of the disease in the child, some tumors of the same character 
were detected on the breast of the mother at which the child sucked. 
The bulk of these latter varied from a pea to a hazel-nut, and on 
being pressed exuded the same milky fluid. A second instance of 
these little tumors occurred in a female child of two years old. They 
were between thirty and forty in number, and were distributed on the 
neck, shoulders, face, and trunk. Their development is ascribed to 
being nursed by a girl who had some tumors on her skin. The third 
example is not so satisfactory ; it is that of a young man who had 
several little tumors on the penis, which he said resembled similar 
tumors situated on the vulva of his wife. Dr. Paterson inoculated 
with some of the milky fluid, but without producing any effect ; he 
gives an admirable description of the minute structure of these tumors, 
and their contents, and a beautiful figure of the disease. 

The remarkable case of albuminous sarcoma of the integument, of 
nearly the entire body, described by Mr. Hale Thomson, 2 under the 
title of "albuminous molluscum," and the case of carcinomatous 
integumentary tumors, detailed by Dr. Turnbull, 3 physician to the 
Huddersfield Infirmary, must be referred to a group, embracing 
diseases in the form of tumors affecting the integument in common ivith 
other tissues of the body. They do not necessarily originate in the 
skin ; indeed, they more frequently take their origin in the subcuta- 
neous textures; they are not limited to the skin, but involve adjacent 
tissues; and they are generally met with in other parts of the body 
as well as the integument. 

Since the publication of the first edition of this work, I have 
repeatedly seen and treated the little tumors described in the pre- 
ceding pages. Nothing is more easy than their removal, and of their 
non-contagious nature there cannot be a second opinion. 

Sebaceous accumulations sometimes present themselves in 
another form, wherein the sebiferous duct and related hair-follicle are 
dilated to an enormous extent, and, pressing on the structure of the 
gland, finally cause its atrophy and absorption : these sebaceous accu- 
mulations attain considerable magnitude; they are generally oval in 
I'm in. and eomel hues measure upwards of an inch in diameter. Their 
precise seat is the tissue of the derma, and they are more or less 
flattened by compression between the deep layer of the corium 

1 Edinburgh Medical and Surgical Journal, vol. Ivi., 1S42, p 279. 

2 Lancet, vol. ii., 1841. Tin; paper is illustrated with two excellent lithographic 
drawings. 

8 Edinburgh Medical and Surgical Journal, vol. Ivi., p. 463. 



584 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

within and the surface of the skin without. The follicular sac is filled 
with a white and concreted substance, which is more or less apparent 
through the dilated aperture of the duct. The opening of the duct, 
however, bears no proportion to the size of the accumulation, and, 
from the little projection of the impacted substance, is the principal 
indication of its existence. The walls of the sac are extremely thin, 
and are lined in their interior with epidermis. Sometimes they are 
beset with hairs. 

On examining the contents of one of these sebaceous sacs, I was 
much struck by finding the contained substance laminated in structure, 
and presenting a silvery hue. The lamination of the substance afforded 
me a convincing proof that the mass was a product of the lining 
membrane of the sac, and its silvery brilliancy further led me to 
believe that it must be composed of epidermal scales. The micro- 
scope established the correctness of this conclusion. Hence, a disease, 
originally a disorder of a sebi parous gland, and of its secretion, 
subsequently becomes one of the hair-follicle. 

Treatment. — The concreted substance may be removed without 
much difficulty, by means of a small scoop introduced through the 
aperture. If the aperture be small, it must be dilated or enlarged 
by means of a trifling incision. After the removal of the concreted 
mass, the internal surface of the sac should be touched with nitrate of 
silver or potassa fusa. 

CORNUA HUMANA. 

Human horns. 

"When the sebaceous substance impacted in the dilated sac of a 
sebiferous duct or hair-follicle in the manner just described, is, by a 
continuance of the process of formation, forced through the aperture 
of the sac, it desiccates in that situation, hardens, and is converted 
into horn. By the addition of fresh layers from below (the formative 
power having increased by the removal of superficial pressure), the 
indurated mass is still further forced outwards, dilating the aperture 
as with a wedge, and finally increasing in size to that of the entire 
base of the hypertrophied follicle. The process of formation of new 
epithelial layers by the walls of the follicle, now become the base 
of the mass, will go on, unless interrupted by surgical interference, 
for years, and in this manner those singular bodies, of which so many 
remarkable examples are on record, horns, are produced. 

A well-marked instance of horn was shown to me by Mr. Barkli- 
more, of Bloomsbury, during the month of October of the year 1843. 
The patient was an old female servant in his family, fifty-seven years 
of age, and gave the following history of her case: At the age of 
five-and-twenty, on the termination of a severe attack of illness, she 
observed a small elevation, like a pimple, on the site of the present 
growth; the pimple inci^eased in size, was somewhat painful, and in 
about ten years from its first appearance burst, and discharged matter 
resembling " mashed potato." Subsequently, a cavity always remained, 
from the bottom of which "scurfy" substance could be raised by the 



DISEASES OF THE SEBIPAROUS ORGANS. 585 

finger nail. At the beginning of the current year the present growth 
made its appearance in the situation of the cavity, and, increasing in 
size, gave her much pain and uneasiness. The skin around it was 
red and inflamed, and she applied a poultice, which had the effect of 
making it grow faster. During the summer she suffered much from 
frequent jerks which the growth' received from her dress, and awk- 
ward blows which it sustained, and in the month of October applied 
to her master for relief. At this period the growth had acquired 
considerable size: it was situated on the upper and front part of the 
thigh, and presented the appearance and characters of horn. It was 
semi-transparent, yellowish in color, dense and horny in texture, 
ribbed on the surface, insensible to the pressure of the nail, and 
firmly rooted in the skin. In general appearance it resembled the 
broad and curved beak of a bird, of large size, and had a broad and 
extensive base. Around the base the integument rose to the height 
of several lines, and in two places to half an inch. The skin was 
thin and attenuated, as though from the effects of stretching, the 
epidermis being continuous with the surface of the horn, and gave 
the idea of a degeneration of the integument into the horny structure. 

On the 12th of October I removed the horn, by cutting through the 
integument around its base, and dissecting it from the subcutaneous 
tissue. The removal was speedily and easily accomplished, as the 
growth was limited inferiorly by the under surface of the corium. 

On examining the horn after removal, I found its base to be formed 
by the deep stratum of the corium, so that it was obviously a cutaneous 
formation. The base was oval in shape, and measured in long dia- 
meter one inch and a half, and in the opposite direction one inch and 
a quarter. The horn was two inches and three quarters in length, by 
two inches in greatest breadth, and its elevation above the surface was 
one inch and a quarter. The latter measurement was that of the ver- 
tical thickness of the horn; for, in consequence of its mode of growth, 
its long diameter lay parallel with the surface of the skin. The seba- 
ceous accumulation must originally have formed a prominent tumor, 
from the side of which the protrusion took place; the thin integument 
covering the other half still retaining its elevation from distension. 
Traces of this mode of formation are still apparent upon the surface 
of the horn. Subsequently the thin integument became inflamed and 
ulcerated, and receiving no granulations from beneath, desiccated 
upon its homy contents. The ulceration was the cause of the redness 
:ui 1 1 pain of which the patient complained, and its extent is marked 
upon the horn by a rough, discolored surface of a circular figure, sur- 
rounded for more than two-thirds of its extent by a margin of thinned 
integument. The weight of the horn was six drachms. 

The sect ion of the growth presents all the characters of horn; it 
is laminated longitudinally, the laminae being distinctly traced, by 
their difference of tint, from the base to the apex. At the apex, it is 
split in the direction of its laminae, and several external lamellae are 
partly separated from those beneath. 

In minute structure it is composed of flattened epithelial cells, 
closely condensed, and in some parts having a fibrous arrangement. 



586 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

The epithelial scales are somewhat larger than those of the epidermis, 
and possess nuclei; a circumstance which confirms the analogy be- 
tween the inflected follicles of the skin, and those larger inflections 
lined by mucous membrane. The flattened cells measured in long 
diameter from 7 ^ to 3^ of an inch; and in short diameter fromy^^ 
to 3!^; the average of these measurements being 3 i^for the long, and 
gi^for the short diameter. The nuclei are, for the most part, oval in 
shape, the long diameter measuring ^q-q, the short 33^^ of an inch. 

I made no chemical analysis of the horn in the present case, but 
this has been done repeatedly on the Continent. M. Dublanc has pub- 
lished an analysis of human horn in the Journal de Pharmacie, ' 
and another analysis was 2 made of a horn, which is deposited in the 
Dupuytren Museum. Both analyses go to show that human horn is 
chiefly composed of albumen, a small quantity of mucus, phosphate 
of lime, chloride of sodium, and a trace of lactate of soda. 

Since the occurrence of the above case, I have met with several 
instances of horn in the human sub- 
ject; one was on the shoulder, two at 
the root of the nose, and one on the 
penis. The latter measures in its dried 
state one inch in length. I have also 
in my possession, the contribution of 
an unknown friend, a fine specimen of 
horn which grew " on the head of an 
adult male during the period of nine 
years." 2 It looks as if it had been 
broken away from its attachment, and 
is twisted like a ram's horn. It mea- 
sures, in its dried state, somewhat 
more than four inches and a half in 
length, and two inches and three-quarters in its greatest circumference. 
The subject of horns in the human person very early attracted the 
attention of observers, and their occurrence seems to have been more 
frequent among our forefathers than at the present day. This circum- 
stance may be explained by referring to the improvement which has 
of late years been made in surgery, and to the more general diffusion 
of a knowledge of its elementary principles. On a recent occasion, 
namely, the presentation of a paper to the Royal Academy of Medi- 
cine of France, by M. Lozes, the committee appointed to inquire into 
this subject collected seventy-one observations of horny growths from 
the skin, of which thirty-seven were met with in females, thirty-one 
in males, and three in infants. Of this number, fifteen were seated on 
the head, eight on the face, eighteen on the lower extremities, eight 
on the trunk, and three on the glans penis. 3 

In pursuing this inquiry, I have succeeded in collecting ninety 
cases, of which forty -four were females, and thirty-nine males; of the 

1 March, 1830. 

* Cruveillner, Anatomie Pathologique, liv. 24, vol. 2; and Jour, de M6d. Prat, de 
Bordeaux, 1835. 

3 Memoires de l*Acad6mie Royale de M6decine, Juin, 1830. 




DISEASES OF THE SEBIPAROUS ORGANS. 587 

remainder the sex is not mentioned. Of this number, forty-eight 
were seated on the head, four on the face, four on the nose, eleven on 
the thigh, three on the leg and foot, six on the back, five on the glans 
penis, and nine on the trunk of the body. The greater frequency of 
this disorder among females than males is admitted by all authors, but 
this fact is most conspicuously shown in the instance of the thigh and 
of the head; for example, of the eleven cases of horny growth from 
the thigh, two only were males; and of the forty-eight affecting the 
head, twenty-seven occurred in females, and nineteen in males ; in the 
remaining two the sex being unmentioned. That old age is a predis- 
posing cause of the affection, is proved by the greater frequency of its 
occurrence in elderly persons ; thus, of the forty-eight cases in which 
the scalp was the seat of the growth, thirty-eight were above the mid- 
period of life; several were over seventy, and one was ninety- seven; 1 
three were young persons, 2 and three were infants. 3 

Cruveilhier, remarking on the relative frequency of these growths 
on different parts of the skin, states that they occur on the posterior 
and inner part of the thigh, as often as on all the other regions of the 
body taken together, a circumstance which he attributes to the general 
use of the chaufferette. But Cruveilhier's statement is not borne out 
by facts, and numerical data are, as we have seen above, opposed to 
his opinion. Moreover, he confounds horns with warts and corns, and 
regards them as the result of cutaneous irritation, and enlarged pa- 
pillae, with increased secretion of epidermis. 4 

Several authors have mentioned the development of horny growths 
from old encysted tumors, and have remarked upon their frequent 
association with such tumors. Sir Everard Home 5 was particularly 
struck with this circumstance; it was present in all the cases which 
he examined, but he fails to account for the horny secretion, which he 
regards as an imperfect substitute for epidermis. Thomas Bartholin, 
who collected several cases of human horns, speaks of the origin of 
one from an encysted tumor, 6 and Soemmering, 7 Gastellier, 8 and Cal- 
dani, 9 notice the same fact. 

Some curious speculations were excited in the minds of the older 
physicians by the observation, of cases of horny growths. Rhodius 10 
met with a Benedictine monk who had a pair of horns, and was 
addicted to rumination, and Fabricius, 11 having seen a man with a 
hum growing from his forehead, whose son ruminated, is willing to 
give the father the credit of transmitting this disposition to the son, 
by virtue of the ruminant character which he bore so obviously upon 
his head. 

1 Gastellier, Hist, de la Soc. Roy. de M6d., vol. i., p. 31 1, 177G. 
8 Aldrovandtu el Bartholinus. 

3 Amatua, Cent, I. Cur. 1, Zacutus Lusitanus, Prax. Med. Adm., lib. iii., obs. 83. Jo- 
seph Lan/.oni, Nat. Cur. I'.pliem. (ji-rm., aim. I, l»>7.'i. 

1 Loc. eitat 

5 Philosophical Transactions, vol. lxxxi , p. 9. r >. 1791. 

6 F.pistnii.-. i Archives Generates de M6d., vol. xHi. L8?7. 
8 Loco citato. 9 Dirt, de Med., art. Corn6e. 

10 Bartholinus, do unicorn, aphor. 

11 De ventriculo. Also, Bartliolinus, de unicorn, aphor. 



588 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

The most remarkable case of human horn on record is that of a 
Mexican porter, named Paul Rodriguez. 1 The horn was situated 
upon the upper and lateral part of the head, was fourteen inches in 
circumference around its shaft, and divided above that point into 
three branches. Voigtel 2 cites the case of an old woman who had a 
horn with three branches growing from her forehead; and M. Dubois 3 
had a woman under his care, in the Hospice de Perfectionnement, 
with a horn that measured seven or eight inches in diameter at its 
base, and was six inches in length. The length of the horn, in some 
recorded instances, is also remarkable. Sir Everard Home 4 saw two 
cases, in both of which the growth measured five inches, by one inch 
in diameter. They were curled, and had the appearance of isinglass. 
In one case the horn was fourteen years growing. Dr. Gregory, 5 
mentions a horn which was removed from the temple of a woman in 
Edinburgh, and measured seven inches. Dr. Chariere, 6 of Barnstaple, 
saw one growing from the nape of a woman's neck, which measured 
seven inches. A horn said to be preserved in the British Museum 
measures eleven inches in length, by two and a half in circumference; 7 
and Bartholin, 8 Faget, and several other writers, have spoken of 
horns twelve inches long. A singular instance of horn is mentioned 
by Cruveilhier, in his Anatomic Pathologique, as falling under the 
notice of Dr. Faget, of Bordeaux. The subject was a Mexican Indian, 
and the horn was situated in the lumbar region, on the left side. 
After growing for three years, it had attained a length of four inches, 
by seven or eight inches in circumference, and was sawn off by the 
patient's son ; after another three years it was submitted to a similar 
operation, and at the end of nine or ten years from its first appearance, 
was extirpated by M. Faget. The portion removed by M. Faget, with 
the two portions previously cut off, amounted in length to about twelve 
inches. 

In a scarce tract in small quarto, published in 1676, there is "a 
brief narrative of a strange and wonderful old woman, that had a pair 
of horns growing upon her head." " This strange and stupendous 
effect," continues the pamphlet, "began first from a soreness" of the 
back part of the head where the horns grew. " This soreness con- 
tinued twenty years, in which time it miserably afflicted this good 
woman, and ripened gradually into a wen, near the bigness of a large 
hen-egg, which continued for the space of five years, more sadly tor- 
menting her than before, after which time it was, by a strange opera- 
tion of nature, changed into horns, which are, in show and substance, 
much like ram's horns, solid and wrinkled, but sadly grieving the 
old woman, especially upon the change of weather." The horns were 
shed four times; the first "grew long, but as slender as an oaten 
straw;" the second was thicker, ane^ on the fall of the latter, two 
were produced which were broken off by accident. One of these was 
presented to the King of France, the other is stated to have been 

1 New York Medical Repository for 1820. 

2 Handbucb citat. 3 Dictionnaire de Medecine, art. Cornee. 
4 Loco citato. 5 Sir E. Home's paper; loco citato. 

6 Eodem loco. 7 Eodem loco. 8 Epistolis. 



DISEASES OF THE SEBIPAROTTS ORGANS. 589 

nine inches long, and two inches in circumference. The periods of 
shedding were three, four, and four years and a half. There is an 
engraving of this woman in Dr. Charles Leigh's Natural History of 
Lancashire, Cheshire, and the Peak of Derbyshire. Her portrait, and 
one of the horns, is in the Ashmolean Museum, and another of the 
horns in the British Museum. 

The authors who have given their attention to this curious subject 
are more numerous than might be expected. Bartholinus and Borellus 
have each collected numerous cases. Vicq d'Azyr 1 treats of the sub- 
ject in his essay on Animal Concretions, in 1780 ; Franc, 2 in an essay 
de Cornutis, in Heidelberg ; Sir Everard Home, in the Philosophical 
Transactions for 1791 ; Alibert, in his Precis Thcorique et Pratique 
des Maladies de la Peau ; Rudolphi, 3 in a paper read before the 
Academy of Sciences of Berlin, in 1815 ; Dauxais, in a thesis, publish- 
ed in Paris in 1820 ; Breschet, in the article " Cornee," in the Diction- 
naire de Medecine ; Cruveilhier, in his Anatomie Pathologique. The 
latter author devotes the whole of his twenty-fourth fasciculus to horny 
growths. And Sir Astley Cooper and Mr. Travers in their Surgical 
Essays. 4 

The following case is strikingly illustrative of the mode of growth 
and appearance of a horn when developed on the face. Louise 
Marino, an Italian peasant, fifty-four years of age, perceived, in the 
month of January, a small tubercle of about the size of a millet-seed 
imbedded in the integument of the root of her nose. The tubercle 
was attended with a trifling degree of pain and pruritus, but continued 
to grow with considerable rapidity. On the 30th of October (same 
year), it had acquired the length of an inch, was of a grayish-brown 
color, had the diameter of a writing quill, was grooved along its under 
surface, and curved like the beak of a bird of prey. It adhered firmly 
by means of a narrow base to the skin and subjacent cellular tissue. 
Dr. Portal removed it by incision ; the cellular tissue at its base, the 
periosteum and bone, were perfectly sound. 5 

A similar case to this, in so far as seat and mode of appearance are 
concerned, has just come under my care. Finding the horn imper- 
fectly adherent to its base, I displaced it with my nail, and applied 
caustic to the surface of the sac, from which it had originated. This 
treatment was successful in preventing its return. Another case of 
horo has lately been recorded by Mr. Dalby, G of Ashby de la Zouch, 
under the incorrect term of " ichthyosis cornea." The horn was six 
inches in length, and two and a half in circumference; it originated in 
:in encysted tumor and grew from the back part of the scalp of an old 
lady, seventy years of age. At one time it gave rise to so much pain 
when touched, that she could not bear to lay her head on her pillow. 
Mr. Dalby's narration is accompanied by a wood-engraving. 

TREATMENT. — The examination of the case mentioned in the pre- 
ceding pages, by showing the true nature of the growth, suggests the 
appropriate mode of treatment, and proves, at the same time, that the 

« Hist, de la Soc. Roy. de McU, p. 184. 1780-81. 

2 Tract. Philolog. Med. de Cornutis. 3 Vol. ii. 

4 Part 2. 6 11 Filiatre, Sebezio, February, 1842. 

6 Lancet, vol. ii. 1850, p. 342. 



590 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

practice heretofore adopted, of removal by incision, is altogether un- 
necessary. It is plain that the indications to be pursued are, 1. To 
soften and dissolve the horn, that it may be displaced without force, 
from its follicular bed ; and, 2. To modify the secreting surface, in such- 
wise as to prevent the continuance of the process of abnormal cell- 
formation. The first of these indications is to be fulfilled by means 
of alkalies and water-dressing, or by a poultice ; the second by the 
stick of nitrate of silver. By these means the growth may be removed, 
the disposition to its reformation checked, and a painful operation 
avoided. 

(b.) Retention of secretion in the sebiferous ducts, the excretory aper- 
ture being closed. 

TUBERCULA MILIARIA. 

Syn. Exormia milium, Mason Good; Crrutum, sive milium, Plenck ; 
Follicular elevations, Rayer ; Pearly tubercles. Der Gries, Germ. 

Little tubercles of a white color, of about the size of a millet-seed, 
and sometimes of a small pea, caused by the collection of the seba- 
ceous substance within an excretory follicle, the aperture of that folli- 
cle being impervious, are very commonly met with on the face and neck 
of women and children, and persons having a thin and delicate skin. 
Rayer calls them follicular elevations, but I have thought the term seba- 
ceous miliary tubercles more appropriate. A very common seat of these 
little elevations is the thin skin of the lower eyelids, where they some- 
times attain an inconvenient size. I have seen several cases in which the 
movements of the lid were interfered with by their growth. They are 
easily removed by puncture with a fine lancet, and gentle pressure ; 
the operation is by no means painful, for the integument covering them 
is reduced by distension to a mere film. Touching the interior of their 
sac with a fine point of nitrate of silver effectually prevents their re- 
turn ; or if they be too numerous for this operation, the attempt may 
be made to disperse them by means of a weak solution of bichloride of 
mercury in almond emulsion. 

In place of sebaceous substance more or less inspissated, it some- 
times happens that the secreted matter partakes rather of the calca- 
reous character, calcareous miliary tubercles, being more or less 
dense and hard, and containing carbonate and phosphate of lime in 
combination. Meckel found a number of these concretions in the 
skin of the gluteal region, and Voigtel 1 records an instance as occur- 
ring on the forehead, and root of the nose. Dr. Julius Vogel 2 has 
described another case of this disease affecting the scrotum. The integu- 
ment of the scrotum was the seat of severe itching : on the cessation of 
the itching a number of small conical tubercles were developed, which 
increased to the magnitude of a pea or hazel-nut. After reaching ma- 
turity, the little tubercles wasted and became dry, and were followed 

1 Handbuch der Pathologischen Anatomie. 

2 Algemeine Zeitung fur Chirurge innere Heillcunde und ihrer Hulfswissenschaften, 
July, 1841. 



DISEASES OF THE SEBIPAROUS ORGANS. 591 

from time to time by successive crops. At the period of detailing the 
case, they were one hundred and fifty in number, seated in or beneath 
the corium. The contents of the tumors were a white, greasy, and 
softish substance, like atheroma. Examined chemically, it was found 
to consist of carbonate and phosphate of lime, with a trace of soda, a 
small portion of fat, and some extractive matter. 

Dalrymple called attention to a similar fact in relation to a small 
encysted tumor of the eyelid, and showed the seat 'of the calcareous 
matter to be the epithelial scales of which the tumor was composed. 
Instead of presenting their natural transparency, the scales "were 
thickened and hard, and contained granular, earthy molecules, which 
could be removed by immersion in weak muriatic acid." Gulliver 
ascertained the earthy matter to be phosphate of lime, with a trace 
of the carbonate of the same earth. 1 Dalrymple informed me that 
he had, since the publication of the preceding, seen a second instance 
of the same disease. 

TUMORES SEROSI. 

Syn. Milia. Plilyctenulce. 

Sometimes, instead of sebaceous or calcareous substance, the excre- 
tory follicles of the sebiparous glands are distended with a limpid 
serous fluid, and attain the size of millet-seed or small grapes. A 
gentleman lately consulted me, in whom there were two of these grape- 
like cysts, connected with the border of the upper eyelid; they were 
semi-transparent and tense, and interfered with his vision. I punctured 
them with a cataract needle, and, after the escape of the fluid, touched 
the shrivelled cysts with nitrate of silver ; the integument soon healed, 
and they are not likely to reappear. The same method of treatment 
is applicable to the smaller kind. 

Occasionally, the fluid is contained in a transparent cyst, so ex- 
tremely firm that the tumor is unable to increase to the size above 
indicated ; and the tension of the sac is so great that it appears to 
have the. density of cartilage. The integument covering these little 
tumors is extremely attenuated and semi-transparent, and small vessels 
are seen meandering over their surface. Their size, transparency, and 
hardness have suggested the terms by which they are commonly 
known ; namely, chalazion, or grando, hailstone. Their treatment is 
the same as that of the miliary and serous cysts, namely, puncture and 
the application of a point of nitrate of silver. 

TUMORES SEBACEI. 

Syn. Emphyma 2 encystis, Mason Good. Encysted tumors. Follicular 
tumors. Wen. Meliceris. Atheroma. Steatoma. 

These tumors, identical in manner of formation with the sebaceous 
miliary tubercles, but somewhat more deeply seated in the integument, 

1 Medico-Cbiiurgica] Transactions, vol. xxvi., 184.3, p. 238. 

2 Der. <piai, produco, erumpo. Mason Good applies the term emphyma to a tumor origi- 
nating below the integument; and erphyma to a tumor confined to the integument: there- 
fore, he is in error in naming the encysted tumor emphyma; it should be, ecphyma. 



592 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

attain to the size of a hazel-nut or walnut, and sometimes the magni- 
tude of a small orange. They may occur singly, or several may he 
developed in the same person, particularly when situated on the head. 
Their common seat is the scalp and face, hut they are occasionally 
seen on other parts of the body. A few years since, I removed one 
of large size from the integument of the back, and have also seen them 
on the abdomen and in the groin. 

The sebaceous substance collected in these sacs is variously altered 
in its qualities or appearance. Sometimes it is limpid and fluid, like 
serum, and contains crystals of stearine ; at other times it is soft and 
white, reminding us of pap, or bread sauce, this constitutes the athe- 
romatous tumor ; again, it is yellowish, and resembles softened bees- 
wax, the melicerous tumor ; or it may be white and fatty, the steatoma- 
tous tumor; at other times, it presents various peculiarities of character, 
more or less referable to the above heads. The parietes of these cysts 
are the walls of the excretory duct of the sebiparous gland and related 
hair-follicle, in a state of hypertrophy, lined in the interior with epi- 
dermis. The sebaceous substance which they contain is mingled with 
epidermal scales and hairs, having a similar origin to those found in 
the sebaceous accumulation of comedones. The contents of the cyst 
are often exceedingly fetid, and the fetor is increased when the tumor 
inflames. In consequence of the pressure exerted on the scalp by these 
tumors, the neighboring hair-follicles are frequently destroyed, and the 
superjacent skin becomes bald. 

The encysted tumors of the eyelids, and some of the polypi of the 
meatus auditorius, are of the same nature. 

Treatment. — The common practice in the treatment of these tumors 
is to dissect them out, and this is usually done with care, under the 
impression that a particle of the cyst left behind will grow, and 
develop another tumor. This reasoning is most unphilosophical, and 
I doubt if empirically it be correct. A portion of the cyst left behind 
may interfere with the healing of the wound, but a portion of cyst can 
possess no power of reproducing a dilated and hypertrophied hair- 
follicle and excretory duct of a sebiparous gland. The removal of 
these tumors is always a painful operation, and in certain cases, when 
seated in the scalp, dangerous, from the possibility of the occurrence 
of erysipelas. I have generally succeeded in curing encysted tumors 
by laying them open with a lancet or bistoury, pressing out their con- 
tents, and injecting the cyst with a solution of nitrate of silver, or 
touching its internal surface with the solid caustic; and this plan I 
prefer to the painful process of excision. 

The contents of these tumors are sometimes too dense to be simply 
squeezed out, and not unfrequently they are soft in the centre and as 
dense as horn in the circumference, looking, in fact, like a horny or 
cartilaginous sac inclosing the softer material. When this is the case, 
after laying open the tumor, I pinch the edge of the horny cyst, and 
gently draw it outwards, while, at the same time, I press back a thin 
fibrous membrane by which it is invested ; in this way the whole of 
the horny cyst may be removed at once, and all subsequent inconve- 
nience prevented; for, when completely removed in this manner the 



DISEASES OF THE SEBIPAROUS ORGANS. 598 

application of caustic is unnecessary, and the wound heals, without 
further attention, in a few days. It may be necessary to remind the 
young operator that the incision, which is least painful when effected 
by puncture with a narrow-bladed knife, should be made in the direc- 
tion of the hair. The operation, neatly performed, is so little painful, 
that I have sometimes removed as many as six or eight in a young 
lady at a single sitting. 

V. INFLAMMATION OF THE CUTANEOUS FOLLICLES WITH DE- 
RANGED EXCRETION OF THE SEBACEOUS SUBSTANCE. 

The only disease coming strictly under this definition is Acne. 

ACNE. 

Syn. Ionthus. Varus. Couperose, Fran. Hautfinne, Kuperfinne 
im Gresicht, Germ. Whelk. 

Acne (Plate XIV.) is a chronic inflammation of the follicles of the 
skin, arising from impaction of the sebaceous substance. It is charac- 
terized by the eruption of hard, conical, and isolated elevations, of 
moderate size, and various degrees of redness. The apices of the ele- 
vations generally become pustular, and burst, while their bases remain 
for some time in an indolent state before they disappear. On the 
apices of some of these elevations the opening of the follicle is dis- 
tinctly apparent, while in others the aperture is destroyed by the 
pustule. In some the purulent fluid is mingled with softened sebace- 
ous substance, while others subside slowly without suppuration. 
Some, again, scarcely differ in tint of color from the adjacent skin, 
while others are highly congested and surrounded by an inflamed base 
of vivid redness. 

Acne is usually accompanied with other signs of disorder of the 
cutaneous follicles: thus, ifi some situations, the glands appear to be 
excited to undue action, and pour forth an inordinate quantity of 
secretion, which gives the skin a glossy appearance ; in others their 
action is torpid, the sebaceous matter is concreted into a solid form, 
and distends the excretory duct and hair-follicle even to the orifice, 
where, coming in contact Avith the dust and dirt diffused through the 
atmosphere, the concreted matter is discolored, and has the appear- 
ance of a brownish or black spot. If a fold of skin including any one 
of these black spots be pressed between the fingers, the concreted matter 
is forced out, and resembles a small white maggot with a black head. 
These concretions are popularly known as maggots or grubs. More- 
over, in this state of skin, a number of small, white, sebaceous miliary 
tubercles may also not unfrequently be observed. 

The term acne seems to be derived from &xvj) or dx/ii), as though it 
would imply that which is indeed the fact with regard to this disease, 
namely, that it prevails during the mid-period of life, from the age of 
puberty to the commencement of old age. It may be developed on 
all parts of the body, but is most frequently met with where the 
integument is thick, as the back, shoulders, backs of the arms and 

38 



594 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

forearms, breast, or those parts which are exposed to the influence of 
the atmosphere, as the face and neck. 

The varieties of acne, according to Willan, are four in number, 
namely, acne .simplex, acne punctata, acne indurata, and acne rosacea. 
The first three are mere modifications of the same form of disease ; 
indeed, the same elevation may, at different periods of its growth, 
present each of the appearances indicated by these designations. I 
shall therefore take the more simple course of describing the affection 
as appearing under two principal forms, namely, 

Acne vulgaris, 
Acne rosacea. 

ACNE VULGARIS. 

Syn. Ionthus varus simplex et punctatus, Mason Good. Whelk. 
Stone-pock. 

The common variety of acne (Plate XIV., A. G.) commences by 
small red and inflamed elevations, which gradually become pro- 
minent and conoid, and secrete a small quantity of pus at their ex- 
tremity, while the base remains hard and of a deep red color, and is 
surrounded by an inflamed areola of small extent. The suppuration 
is slow in attaining its completion, usually continuing for six or eight 
days ; at the end of this period the pustule bursts, and the effused 
fluid desiccates into a thin brownish scab, which leaves at its fall an 
indolent tubercle of a purplish livid hue (*ov0oq ab *ov, viola), and fre- 
quently a small white and permanent cicatrix. The tubercle remains 
for a considerable period after the rupture of the pustule, and dis- 
appears very slowly. The eruption of acne is generally unaccom- 
panied by pain or heat, and gives rise to little inconvenience beyond 
that which is caused by its unsightly appearance. When, however, 
it is developed near a filament of a sensitive nerve, as of the fifth, 
upon the forehead, the pain is sometimes very distressing. The ele- 
vations of acne are for the most part successive in eruption, and may 
be observed at the same moment in all their stages ; at other times, 
and more rarely, a numerous crop may be developed at once. 1 

It frequently happens that in the centre of each of the conical ele- 
vations, and always in some, a small round blackish spot may be 
perceived. The presence of this spot is the especial characteristic of 
acne punctata 2 (Plate XIV., a. b. c.) ; it is the aperture of a hair- 
follicle, distended with inspissated sebaceous substance up to the level 
of the skin, and discolored at the surface by exposure to the dust and 
dirt contained in the atmosphere. After having suppurated and dis- 
charged the sebaceous substance, the elevations diminish in size; they 
become purplish and livid, and, at a later period, whitish in color, 
and disappear by degrees. The punctated form of acne is generally 
intermingled with that in which the excretory puncta are obliterated. 

1 For a good example of acne vulgaris, presenting at the same view all its various forms, 
see " Portraits of Diseases of the Skin.' - Plate XXXIX., I. 

2 Acne punctata, or maggot pimple, is consequently a comedo, with the superaddition 
of inflammation of the cutaneous follicle. 



DISEASES OF THE SEBIPAROUS ORGAN'S. 595 

Occasionally, the eruption is remarkable for the indolence of its 
course ; the inflamed elevations are very hard, and deeply rooted in 
the integument ; the suppurative stage is prolonged two or three 
weeks before reaching its height, and frequently fails altogether, and 
after suppuration is completed the purplish or livid tubercles continue 
for months, sometimes becoming permanent, and at other times leaving 
indelible cicatrices; this is the acne indurata (Plate XIV., D.) When 
the indolent form of acne affects the face extensively, the features 
are disfigured ; the entire surface is more or less covered with 
tubercles of a deep red or livid color and variable size, and the inte- 
gument between the tubercles is thickened and congested. The face 
and back are the more common seat of this eruption. 

ACNE ROSACEA. 

Syn. lonthus corymbifer, Mason Good. Bacchia. Gutta rosacea. 
Rosy-drop. Carbuncled face. Grog-blossom. BubuMe. 1 

Acne rosacea (Plate XIV., h.) is especially characterized by the 
redness and congestion which attend its conoidal elevations ; by the 
enlargement and frequently varicose state of the veins of the derma ; 
by the tardiness of course of the papular elevations ; the slowness 
of their suppurative stage, and the indolent character of the livid 
and indurated tubercles which they leave behind. The integument 
around the elevations is of a deep purple or violet hue, the con- 
gestion is increased by a continuance of the causes which gave rise to 
the disease, and the skin of the affected parts becomes permanently 
thickened, uneven, and tubercular. The more usual seat of acne 
rosacea is the nose, which is often considerably enlarged by the morbid 
action ; the integument and subcutaneous textures become infiltrated 
and hypertrophied, and the cutaneous veins tortuous and varicose. 
From the nose the disease extends to the cheeks, forehead, chin, 
indeed to the entire face, disfiguring the features very seriously. 2 
The congestion of acne rosacea is increased towards evening, by taking 
food, and by the use of every kind of stimulant taken internally. 

Diagnosis. — The diagnostic characters of acne, are, the conoidal 
form of* the inflamed elevations, the suppuration of some of these eleva- 
tions at their apices, the tardy growth and disappearance of others, 
the livid and indolent tubercle left behind by both, their evident seat 
in the cutaneous follicles, and the disorder of neighboring sebiparous 
glands evinced by the increased secretion of some, the concretion of 
the secretion of others, and the presence of sebaceous miliary tuber- 
cles. The particular characters distinguishing the varieties of acne 
are, the absence of any appearance of excretory follicle in acne vul- 
garis; the presence of an excretory aperture in acne punctata; the 
indolent course of acne indurata, and the general distribution of all these 
varieties over the surface of the body. Acne rosacea is distinguished 
from the preceding by the greater vascularity of the elevations, the 

1 "His face is all Inihnkles ami whelk.-, and km, lis, ami (lames of fire." — SllAKSPEARE. 

2 ■• Portraits of Diseases of the Skin. : ' Plate XL., AP. 



596 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

congestion and thickening of the surrounding skin, and the especial 
seat of the eruption on the face. 

Causes. — Acne vulgaris is developed at all ages between the period 
of puberty and the fortieth year, and occurs in both sexes, more fre- 
quently, perhaps, in the female than in the male. Acne rosacea is a 
disease of adult life, and is also more frequent in the female than in 
the male. The presence of acne indicates a disordered state of cuta- 
neous innervation, and, consequently, of the vascular action of the 
skin ; in some instances it is induced by direct congestion of the inte- 
gument, as in acne rosacea, while in others it would seem to depend on 
torpidity of the capillary circulation, and obstruction of the current of 
blood by sudden and irregular excitation. Torpidity of the capillary 
circulation is indicated by the altered secretion of the sebiparous glands, 
which so constantly accompanies the disorder, and, indeed, by the 
general want of cutaneous activity in persons so affected. The latter 
cause is present for the most part in the acne of young persons, in 
that which occurs at puberty, or as a consequence of close application 
and sedentary employment, or mental fatigue. This kind of disorder 
of the cutaneous functions is also associated with amenorrhoea. 

Congestion, on the other hand, is the active agent in the eruption 
when arising from general plethora, from the partial plethora which 
occurs at the critical period of life in females, from exposure of the 
face to heat, from excesses in diet or stimulating drinks, from the use 
of cold drinks in a heated state of the body, and from the local appli- 
cation of irritating substances. Of the latter it is proper to mention 
the abuse of certain stimulating washes and powders employed as cos- 
metics. Partial congestion would seem to be the exciting cause of the 
eruption, when it is induced by irritation of the gastro-pulmonary 
mucous membrane. 

Prognosis. — Acne vulgaris is removed with difficulty ; the rosace- 
ous variety is less intractable. 

Treatment. — The treatment of acne must be adapted to the cause 
of the affection ; in those cases in which a torpid action of the cutane- 
ous system is evident, stimulating remedies must be employed, whereas 
in those which are dependent on congestion, stimulants would be inju- 
rious, and would prolong the morbid action. In both cases the regi- 
men should be regulated ; it should be moderate and nutritious, all 
stimulants avoided. To this hygienic management, laxatives, anta- 
cids, and tonics may be added, with a view to order the secretions, and 
regulate the digestive functions. Whenever other general indications 
present themselves, they must be especially attended to ; thus, in 
young women at the period of puberty, the state of the uterine func- 
tions must be ascertained, and at the critical period of life derivative 
measures may be employed with advantage. Whenever the indication 
is obviously congestive, bleeding may be had recourse to locally. 

In applying the local treatment, due regard should be had to the 
ordinary principles of surgery ; when the pimple is congested and 
painful, it may be punctured, and the bleeding encouraged by water- 
dressing or poultice ; and where pus or sebaceous substance is sus- 
pected to exist imbedded in the tubercle, a free puncture, succeeded 



DISEASES OF THE SEBIPAROUS ORGANS. 597 

by a poultice, is especially indicated. When the local determination 
has somewhat subsided, stimulants may be employed ; for this purpose, 
a lotion containing sulphur sublimatum, two drachms ; camphor, one 
drachm ; and distilled water, four ounces, is often of service ; or the 
hypochloride of sulphur ointment ; or an ointment of ioduret of sul- 
phur, in the proportion of ten grains to the ounce of elder-flower oint- 
ment or simple cerate. In the simple, as well as in the other varieties 
of acne, when they present a chronic character, a solution of the bi- 
chloride of mercury in emulsion of bitter almonds, or of the same salt in 
eau de Cologne, in the proportion of a grain to an ounce, will be found 
of service. A solution of sulphur, in spirit of wine or brandy, has 
been recommended as a local application, but this merely acts upon 
the general principle of stimulation, and is inferior in every respect to 
the solution of the bichloride. 

VI. CARCINOMA OF THE SEBIPAROUS GLANDS. 

TTTBERCULUM MALIGNUM. 

Malignant tubercle. 

In persons beyond the age of fifty, and in elderly persons, we occa- 
sionally meet with a small, hard, indolent tubercle, on some part of 
the skin of the face. This tubercle is evidently of a malignant nature, 
but differs from other malignant affections in the extreme tardiness of 
its progress, and the little inconvenience to which it gives rise. 

The characters of the malignant tubercle are as follows : A tuber- 
cle, rounded or lobulated, elevated about one line above the surround- 
ing skin ; convex at first, subsequently flattened ; hard, colorless, 
yellowish, or purplish, and semi-transparent, having small veins 
meandering over its lobulated surface ; increasing slowly in circum- 
ference by the development of new lobules ; superficial, being limited 
to the skin, and in its early stages to the superficial stratum ; at first 
not more than two lines in diameter, commonly reaching a diameter 
of four or six lines, and sometimes one or two inches ; during its 
growth becoming depressed in the centre from the fuller development 
of the lobulated border. Subsequently, the centre desquamates, then 
becomes fissured and split into several masses ; from these cracks, 
often deep, there issues a colorless or semi-purulent ichor which dries 
on the surface, and forms a rugged, horny-looking crust; frequently 
the cracks bleed and the crust is blackened. At a more advanced 
period, the whole central part becomes covered with a black crust, 
which spreads almost to the border, leaving the latter marked by all 
the characteristic signs of the original disease, namely, rounded, 
lobulated, semi-transparent, and traversed by small venous trunks. 
By degrees, a slow destruction and removal of the central part of the 
diseased growth, scarcely amounting to ulceration or sloughing, takes 
place; the surface continues to be concealed from view by a thick 
black crust, the crust is cracked in one or two places for the exit of 
a sanguinolent ichor, and is separated from the growing border of 
the tubercle also, by a deep fissure through which the same sanguino- 
lent ichor escapes ; the fissure gives the internal edge of the border 
the appearance of a vertical section; sometimes this border is exca- 



598 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

vated, and not unfrequently a little everted. When the black crust 
is removed by means of a poultice, the surface is uneven, composed 
of red, tumid, and bleeding granulations, sometimes assuming a 
fungous character, and sometimes rising in the centre above the level 
of the border ; immediately beneath the edges the sore is more deeply 
excavated than elsewhere. 

The situations in which I have seen the malignant tubercle are, the 
ala of the nose, the groove between the ala of the nose and the cheek, 
the tip of the nose, the superciliary ridge near the temple, the temple, 
the cheek, the integument immediately in front of the ear, and the 
integument over the mastoid process. In seven cases, the measure- 
ments were : three, four lines ; two, six lines ; one, an inch and a half 
in length, by one inch in breadth ; one, nearly three inches in 
diameter ; six occurred in the male, one only in the female. The 
respective periods during which the tubercles had been in existence 
varied between two and fifteen years. 

The pain accompanying this tubercle is generally insignificant, and 
is rather uneasiness than pain ; sometimes there is a little itching, 
sometimes a throbbing ; in a few instances an occasional lancinating 
pain, but more frequently a sensation of numbness or heaviness, or a 
dull aching. It generally fluctuates with the state of health, being 
comparatively easy when the functions are regular, and painful or 
congested when the digestive organs or general health are disturbed. 
In one patient, the tumor was always painful when an attack of gout 
was impending, and w T as relieved by its outbreak. 

Diagnosis. — The malignant tubercle might be mistaken for a wart, 
at least by the patient ; not, however, by the surgeon, when the nature 
of the two formations is considered ; the wart being a product of the 
epidermis, the malignant tubercle an organic alteration of the derma. 
I suspect, however, that some of the cases recorded as cancerous ivarts 
were in reality the tubercles now described. A more probable error 
would be, to confound it with a hairless mole ; but the mole is simply 
an hypertrophy of the natural skin, the skin retaining its normal 
qualities of softness and texture ; while the malignant tubercle is 
of cartilaginous hardness. In its crusted state, it might be taken for 
a dilated sebaceous follicle, and the crust for desiccated sebaceous 
substance, which it much resembles. 

Cause. — The question of cause involves that of the pathology of 
the disease ; it has appeared to me to originate in a sebiparous gland, 
to be, in fact, a cancer of the gland ; and this belief suggested its 
consideration among the group of diseases of those glands. At first, 
one gland alone may be affected, then a second, a third, and a fourth 
become added to the first ; the next step would take the immediately 
adjoining gland around the whole periphery of the tumor ; hence, 
the extreme indolence of the disease at first, and its quicker growth 
afterwards. From the glands the cancerous degeneration is propa- 
gated to the rest of the skin, and the entire mass is involved in one 
diseased action. With this view of the pathology of the malignant 
tubercle, which I regard as a carcinoma glandula* sebiparo3, we may 
refer its cause to a morbid process set up in the structure of the 



DISEASES OF THE HAIR. 599 

gland. Associated with this disease, there are always indications of 
torpor of the skin, and irregularity of its secreting functions ; and not 
unfrequently concretions of sebaceous substance, analogous to those 
of ichthyosis sebacea. 

Prognosis. — The malignant tubercle may be removed with the 
most complete success, on account of its superficial position in the 
skin; and there is little probability of other glands becoming affected 
in a similar manner. The seven cases above referred to were all suc- 
cessfully cured. 

Treatment. — The malignant tubercle must be destroyed thoroughly 
by caustic ; and, for this purpose, the potassa fusa, chloride of zinc, or 
nitric acid, may be employed. I have used all these caustics, and am 
at a loss to give a preference to either. The potassa fusa is, perhaps, 
the least painful, and the chloride of zinc the most so; the potassa 
fusa is rapid in its action, and sinks quickly into the substance of the 
tubercle, while the chloride of zinc produces the cleanest sore. Lat- 
terly, I have selected the nitric acid ; the mode of using it is to mix 
it with sulphur sublimatum to the consistence of a thin paste, and 
apply the paste to the surface of the tubercle by means of a small 
glass or wooden spatula. It requires no subsequent attention, unless 
there be swelling and pain, in which case the part may be fomented, 
and covered with water-dressing. The pain lasts for five or six hours, 
and then ceases ; and the old aching or benumbed uneasy feeling in 
the tubercle is found to be gone. When the eschar falls, the surface 
is generally healed, or nearly so, and requires only a simple dressing 
for a few days. 



CHAPTER XXII. 

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN. 
DISEASES OF THE HAIRS AND HAIR-FOLLICLES. 

The hair is liable to a variety of modifications; some resulting 
from altered nutrition, others from inflammation, either of the forma- 
tive structure of the hair, or of the hair-follicles. Mason Good groups 
all these alterations under the general head TRICHOSIS, the ninth genus 
of his class eccritica; and lie defines trichosis 1 as a "morbid organiza- 
tion or deficiency of hair." These modifications, alterations, and 
discuses, I propose to consider, under the six following heads, namely, 

Augmented formation of hair, 

Diminished formation of hair, 

Abnormal direction of hair, 

Alteration of color of hair. 

1 diseases of the hair, 

Diseases of the hair-follicles. 

1 Trichosis, a term employed by Actuarius, is derived from ipr/un;, pilare malum, mor- 
bid hair; ab fy/f. pilus. 



600 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 



I. AUGMENTED FORMATION OF HAIR. 

Augmentation of formation of the hair calls for consideration in a 
twofold point of view ; firstly, as it relates to simple increase of quan- 
tity or length in situations naturally occupied by hair, abnormal quan- 
tity, hirsuties ; and, secondly, to increase of quantity or length in 
unusual situations, abnormal situation, nosvi pilosi. 

HIRSUTIES. 

Trichosis hirsuties, Mason Good. Die Haarigkeit. 

Great variety is met with among individuals in relation to quantity 
of hair ; in some persons the hairs are collected into groups of three, 
and in many situations two issue from the aperture of the same folli- 
cle ; while in others the hairs are distributed singly at regular dis- 
tances, and are not clustered. 

In the present age, when custom and convenience call for the 
frequent shortening of the hair, we can form very little notion of 
differences involved in rapidity of growth. There can be no doubt, 
that in some persons the growth of hair is more active than in others, 
but to what extent this difference may be carried is unknown. 
Judging from female hair, which is permitted to grow to its full 
length, as well as from hair on other parts of the body, we may rightly 
infer, that hair left to itself grows to a certain length, and then falls 
off, to be replaced by a fresh growth. Withof estimates that the hair 
of the beard grows one line (French) in the course of a week, let us 
call it one line and a half (English) ; this would amount to six inches 
and a half yearly ; and if we suppose, with Withof, that the hair 
continues to grow at this rate for fifty years, the old man of seventy 
must have retrenched his beard upwards of twenty-seven feet in 
length. Berthold states the growth of the hair in persons between 
the ages of sixteen and twenty-four to be nearly two lines a week, or 
seven lines a month, and from six to eight inches a year. He found 
it grow more rapidly after cutting ; during the day than at night ; 
and in warm than in cold weather. 1 Men with long hair are fre- 
quently met with at our country fairs, and Rayer quotes the following 
instance of remarkable development of this production : " I once 
saw a Piedmontese, aged twenty-eight, strongly built, having the 
chest broad and large, and the muscles of an athlete ; the arm was 
above twenty-one inches, and the calf of the leg nearly two feet in 
circumference. This man had little beard, and the trunk was very 
scantily furnished with hair, but his scalp was covered with the most 
extraordinary crop ; frizzled on purpose, it was above four feet ten 
inches in circumference ; the hair was of a dark brown, approaching 
to black, extremly fine and silky." 

It is interesting to remark, that increase in length of the hair is 
sometimes associated with disease ; and in truth we know little of the 

1 Muller's Archiv. 1800. 



DISEASES OF THE HAIR. 601 

effects produced upon the system by the habit of removal of the hair. 
I have known persons who always experience headache after having 
the hair cut, and many cases are on record in which the removal of 
the hair is supposed to have given rise to remarkable results. Moreau 
has published some excellent observations' on the advantages and 
dangers of cutting the hair ; and he especially details the case of a 
young lady cured of mania by that operation. The hair is often 
found of unusual length in phthisis, and long black eyelashes are 
considered pathognomonic of strumous disease. This is an interest- 
ing observation in relation to phthisis, inasmuch as it serves to 
illustrate, in another point of view, the vicarious activity which the 
skin assumes in disordered function of the lungs. 

N.EVI PILOSI. 

Syn. Spilus. Moles. Noevi Materni. Mother s Marks. 

When it is recollected that every part of the skin, with the excep- 
tion of the palms of the hands and soles of the feet, is organized for 
the production of hair, it will cease to be matter of surprise that, 
under certain circumstances, hair should be found to grow to a 
remarkable length in unusual situations. The proximate cause of this 
increased growth is augmented nutrition of the hair-bulbs, determined 
by local or constitutional conditions, the local conditions being either 
special organization of the skin or external irritation of that organ. 
In both, the skin presents a deeper tint than usual, from increased 
formation of pigment in the cells of the rete mucosum, and a greater 
thickness from hypertrophy of the hair-bulbs and follicles. 

Local increase of length of hair, depending on special organization 
of the skin, is usually congenital, and is exemplified in the various 
forms of pilous ncevi, or moles. In nsevi of this kind there is no 
hypertrophy of the capillary structure of the skin, as in vascular 
ngevi, but simple augmentation of color, the consequence of increased 
activity ; and augmentation of thickness, the natural result of enlarge- 
ment of the hair-follicles and bulbs. Pilous nsevi appear in various 
numbers, and in patches of different size, upon all parts of the body. 
They are slightly raised above the level of the surrounding skin, and 
are covered with hair of variable length. Alibert records the case of 
a young lady, whose skin was studded, over nearly every part of the 
body, with moles of a deep-black color, from which a long, black, 
thick, and harsh woolly hair was produced. ViHerine*, in his article 
on the Hair, in the Dictionnaire des Sciences Medicales, observes, " I 
saw at Poictiers, in 1808, a poor child between six and eight years of 
age, that had a great number of mother's marks disposed in brown 
projecting patches of different dimensions, scattered over various 
parts of the body, with the exception of the feet and hands. The 
spots were covered with hair, shorter, and not quite so thick as the 
bristles of a wild boar, but presenting considerable analogy with them. 

1 Journal G6n6ral tie Medecine, vol. iv. p. 280. 



602 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

This hairy covering, with the spots upon which they grew, occupied, 
perhaps one-fifth of the surface of the body." 

Sometimes the disposition to the growth of hair is not confined to 
so limited a spot as a nsevus, but exists over a surface of considerable 
extent. A few years since, I saw a young lad, about twelve years of 
age, of healthy aspect and constitution, who presented a most unusual 
growth of long, harsh, and black hair upon the outer side of the 
arms, extending from the back of his hands to the shoulders. The 
integument upon which the hair grew was of a brownish color, and 
contrasted remarkably with the lighter-colored skin of the rest of his 
arm, and of the body generally. The contrast was less striking near 
the circumference of the hairy growth, from the brownish tint termi- 
nating imperceptibly in the ordinary color of the cutaneous surface. 
The skin, in other respects, was uniform with the rest of the 
integument ; it was neither raised nor tumefied, nor did it differ in 
temperature from the neighboring parts. The hairs in this case were 
about three-quarters of an inch in length, darker in color than the 
hair of the head, conical, and differing from the eyelashes in being 
longer and finer. Examining the skin with a lens, the hair might be 
seen extending deeply, in an oblique direction, into the integument. 
On plucking out some of the hairs, and placing them in the field of the 
microscope, I found them provided with a bulb, and identical in 
appearance with the hairs of the head, or of the whisker. 

Schenkius and Ambrose Pare* record instances in which the body 
was completely covered with hair ; and Daniel Turner relates, quoting 
from Peter Messias, on the authority of Damascenus, " that upon the 
confines of Pisa, at a place called the Holy Rock, a girl was born all 
over hairy, from the mother's unhappy ruminating, and often behold- 
ing the picture of St. John the Baptist, hanging by her bedside, drawn 
in his hairy vesture." 

Bichat, in his treatise on General Anatomy, remarks, that hairs are 
occasionally developed on the surface of mucous membranes, as in 
the bladder, stomach, and intestines ; he also discovered them on the 
surface of renal calculi. In the gall-bladder he once found about a 
dozen hairs, evidently implanted by the roots in the tissue of the 
mucous membrane. Villerme' states, that hairs have been found on 
the tongue, pharynx, in the rectum, uterus, and vagina, growing from 
the mucous membrane. 

Local increase of length of hair, depending on external irritation 
of the skin, is illustrated in the following cases : In a little girl reco- 
vering from an attack of fever, a considerable growth of hair took 
place on the site of a blister which had been applied to the nape of 
the neck. The hair in this case increased to the length of half an 
inch, but evinced no disposition to grow longer ; it was nearly as 
dark in color as that of the head, was harsh, but smooth, and thickly 
planted in the skin. Rayer records a parallel case ; and Boyer was 
wont, in his lectures, to speak of a man who suffered from an inflamed 
tumor in the thigh, which subsequently became covered with numerous 
long hairs. Rayer mentions another case, occurring in a medical 
student, who had several hairy patches on the skin, induced, appa- 



DISEASES OF THE HAIR. 603 

rently, by frequent bathing in the summer season, and exposure to 
the scorching rays of the sun. 

Augmented growth of hair in abnormal situations, arising from 
constitutional conditions, is illustrated in numerous instances which 
have from time to time been recorded. In some of these the unusual 
growth appears to result from general disorder of the system ; in 
others it is the consequence of a particular modification of the eco- 
nomy. Of the former kind is the case of a young lady, narrated by 
Ollivier •} she was remarkable for the whiteness of her skin, and for a 
fine head of jet-black hair; while recovering her strength after the 
effects of a chronic gastro-enteritis, she perceived one day that the 
entire surface of her skin, both on the trunk and- extremities, was 
raised into small pimples, resembling those produced by cold, and 
commonly called goose-skin. At the end of a few days the pimples 
presented a small black head, and shortly after they were found sur- 
mounted by a short hair, which grew very rapidly ; so that at the end 
of a month every part of the body, with the exception of her face, the 
palms of the hands and soles of the feet, was covered with a short 
hairy coat. The individual hairs reached the length of an inch, and 
were closely planted. 

Hair is sometimes developed to a considerable length on the upper 
lip and chin of women at different periods of age. It occurs most. 
frequently in those possessed of a naturally strong growth of hair, 
and of a dark complexion. In young women it is frequently asso- 
ciated with disturbed menstrual function. This fact is observed by 
Hippocrates ; but I have seen several instances in which no such 
disturbance existed, where the vital functions were well performed, 
and where the subjects were remarkable for robust health. The 
development of hair upon the upper lip and upon the chin is more 
common in unmarried females of a certain age, in whom, from inaction, 
the ovaries have become atrophied ; it is also observed in sterile 
married women. In both these cases other changes, evincing the 
deprivation of the peculiar characteristics of the sex, are observed, 
such as dwindling of the mamnise, absorption of the subcutaneous 
adipose tissue, harshness of voice, masculinity of deportment and of 
action. A similar condition is remarked in women who have ceased 
to menstruate, either from natural or pathological causes. John 
Hunter, alluding to the circumstance of female birds, after having 
ceased to breed, assuming the plumage and other attributes of the 
male, says, "Wo find something similar taking place even in the 
human species, for that increase of hair observable on the faces of 
many women in advanced life is an approach towards the beard, 
which is one of the most distinguishing secondary properties of man." 
"The female, at a much later time of life, when the powers of propa- 
gation cease, loses many of her peculiar properties, and may be said, 
except from mere structure of parts, to be of no sex, even receding 
from the original character of the animal, and approaching in appear- 
ance towards the male, or perhaps more properly, towards the herma- 
phrodite." 

1 Dictionnaive de Medecine, article Foil. 



604 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

Treatment. — Where the growth of hair has become a deformity, 
which the patient is desirous of having removed, several modes of 
local treatment may be adopted. If its seat be isolated and small, as 
on a pilous ngevus, the best treatment is excision, which, when care- 
fully performed in the direction of the natural furrows of the skin, 
scarcely leaves any trace of cicatrix. Another mode of getting rid 
of hair is by means of the ciliary forceps or tweezers. Their com- 
plete eradication will, however, be found difficult; for the formative 
organ still remains, and the hairs are constantly reproduced. A 
third mode of removing hair is by depilatories ; these are powders 
composed of quick-lime, subcarbonate of soda, or potash, and sulphuret 
of arsenic. They are applied in the form of a paste, and washed oif 
as soon as dry ; they act by desiccating and dissolving the hair, and 
require to be employed with caution, on account of their irritating 
nature. Depilatories are merely temporary removers of the hair ; 
for it is clear that their agency can extend no deeper than the 
epidermis; the hair-bulbs consequently remain, and the hair is not 
long in being reproduced. I have seen deep and troublesome ulcera- 
tions produced by the incautious use of depilatories. 

II. DIMINISHED FORMATION OF HAIR. 

Diminished quantity of hair, from diminished or arrested forma- 
tion, presents itself in various degrees, of which, simple thinning of 
the hair, defiuvium capillorum, may be taken as the earliest stage, and 
complete baldness or alopecia as the last. 

DEFLUVIUM CAPILLORUM. 

Syn. Athrix simplex, Mason Good. Xerasia. Die Dunhaarigkeit. 

Defiuvium capillorum, the simple and progressive fall of the hair, 
giving rise to thinness, is an affection of the general surface of the 
scalp, but more conspicuous at the partings and more obvious in 
woman than in man from the manner of wearing the hair. Defiuvium 
capillorum, in a small degree, is the common physiological phe- 
nomenon occurring once in the year, generally in the autumn season, 
and corresponding with the change of coat in quadrupeds, and the moult 
of birds, but is less observable in man than among animals. At other 
times it is occasional and accidental, being dependent on some change 
in the functions or health of the individual, and most complete and 
serious where the general health has undergone deterioration. The 
change is often rapid ; in the course of a few weeks an abundant 
head of hair may be transformed into a thin and scanty thatch, barely 
sufficient to hide the white skin from which it grows. If the scalp 
be carefully examined in these cases it will be found to present 
various morbid characters ; sometimes the skin is dry, scurfy, and 
hot, and exhales an unpleasant odor ; sometimes it is polished, and 
has the aspect of being relaxed, the pores are large and dilated ; and 
at other times there may be extensive concretions of desiccated 
sebaceous substance. The hair also exhibits a variety of appearances, 



DISEASES OF THE HAIR. 605 

of which the chief is a dry and parched look, and a degree of rough- 
ness, resulting from the admixture of hair of every length ; this 
roughness and unevenness being partly the result of the broken state 
of the hair, and partly of irregular reproduction, some of the young 
hairs being moderately thick, but the greater part fine and silky, with 
very little hold on the skin. 

In defluvium capillorum the hair is sometimes combed out in 
prodigious quantities, and if the roots be examined they will be 
found thinner than the shaft, showing the eifects of exhausted 
nutrition, and, not unfrequently, the root is embraced by a small 
mass of hardened sebaceous substance. The exhaustion of the 
follicle continues for a long time after the fall of the hair, making no 
effort to reproduce it, and when at last the effort is made, the resulting 
hair is either too thin to maintain its position, or is twisted and 
crinkled, giving rise to the expression withered hair ; or it is thick, 
harsh, and stumpy, its powers of growth being expended in bulk instead 
of in length. 

In the treatment of defluvium capillorum, it is necessary to adapt 
our remedies to the state of the skin as now described: when the 
proximate cause of the fall is an erythematous state of the hair- 
follicles, we must prescribe a cooling wash, gentle brushing, and 
probably an abstinence from grease. When the pathological state is 
want of tone and vigor in the skin, plentiful brushing becomes 
desirable ; a more or less stimulating wash ; and a stimulant 
pomatum. 1 But while these medical means are being pursued, it is 
necessary to treat the hair surgically ; the short hairs, the growing 
hairs, the broken and the withered hairs must all be cut, and the opera- 
tion should be performed once a month, until the weak hairs have 
grown to a normal and uniform length. There is considerable art in 
this operation, the separate hairs require different degrees of cutting ; 
some to be clipped down to the level of the skin ; others to have the 
whole of the twisted or withered part removed ; and others again to 
be simply tipped. This method of cutting was first brought to my 
notice some years back by a hairdresser of Cheltenham, Williams, 
and I have been much gratified by observing its success ; as a mere 
physiological experiment it is curious and extraordinary to note how 
much the human hair may be improved in appearance and growth by 
so simple a process : 

" There are more things in heaven and earth, Horatio, 
Than are dreamt of in your philosophy." 



ALOPECIA. 

Alopecia, or baldness, results from defective development or atrophy 
of the formative organ of the hair, and occasionally from disturbed 
circulation in that structure. Sometimes the baldness is congenital; 
at other times it is accidental, appearing after the full growth of the 

1 Forms of these applications will be found among the " selected formulae" at the end of 
the volume. 



606 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

hair, and causing its fall to a greater or less extent ; and again, it may 
be the natural consequence of age, calvities. Under these three heads, 
therefore, I propose to consider the phenomena presented by the de- 
fective state of formation of the hair. 

CONGENITAL ALOPECIA. 

Congenital baldness is sometimes, but very rarely, observed in 
newly-born infants, in whom, though well formed and healthy with 
regard to every other function, the hair has been retarded in its ap- 
pearance until the end of the first year, and sometimes as late as the 
second and third year. I have seen only a few instances of congenital 
absence of the hair of the head, but I have met with cases of deficiency 
in other regions more frequently, as upon the chin and pubes. " Con- 
genital absence, and ulterior defective development of the hair," says 
Rayer, " are phenomena of considerable rarity, which I have, never- 
theless, had opportunities of observing. Such was the case of the 
man Beauvais, who was a patient in the Hopital de la Charite - , in 
1827. The skin of this man's cranium appeared completely naked ; 
although, on examining it narrowly, it was found to be beset with a 
quantity of very fine, white, and silky hair, similar to the down that 
covers the scalp of infants ; here and there, upon the temples, there 
were a few black specks, occasioned by the stumps of several hairs 
which the patient had shaved off. The eyebrows were merely indi- 
cated by a few fine and very short hairs ; the free edges of the eye- 
lids were without cilia, but the bulb of each of these was indicated by 
a small whitish point ; the beard was so thin and weak, that Beauvais 
only clipped it off every three weeks ; a few straggling hairs were 
observed on the breast and pubic region, as in young people on the 
approach of puberty ; there were scarcely any under the axillae; they 
were rather more abundant on the inner parts of the legs ; the voice 
had the pitch and intonation of that of a full-grown and well-consti- 
tuted man. Beauvais is not deficient in the virile indications of his 
sex ; he has had syphilis twice. He tells us that his mother and both 
his sisters had fine heads of hair; whilst his father presented the same 
defect in the commodity of hair which he does himself." 

ACCIDENTAL ALOPECIA. 

Syn. Porrigo decalvans. Alopecia areata ; circumscripta. Area. 
Area diffluens ; serpens. Tyria. Ophiasis. 

Accidental baldness is a more common affection than congenital 
deficiency of development of hair. I have seen numerous instances, 
in which the baldness has been general and nearly complete upon the 
scalp, one or two small islets of hair-bearing integument alone remain- 
ing, while the hair of the eyebrows, whiskers, and beard, was totally 
lost. In one of these cases the scalp was smooth and polished, thinner 
than natural, and somewhat stretched over the cranium, giving the 
idea of an abnormal increase in the convexity of the bones of the 
head. There was, however, no such condition present. When ex- 



DISEASES OF THE HAIR. 607 

amined closely, the scalp was seen to be studded with numerous, 
superficial, minute, dusky points, the almost obliterated hair-follicles. 
In the course of a few months from this time, with appropriate treat- 
ment, the tenseness, thinness, and polish of the scalp became diminish- 
ed ; the follicles could be seen extending to a greater depth into the 
scalp ; and the mouth of each follicle became the seat of a small 
pimply elevation of the epidermis. This I regard as the commence- 
ment of the second and restorative stage of the disease; the entire 
surface at this period has the appearance of the cutis anserina, and, in 
the course of a few days, a minute downy hair may be seen extending 
from the apex of each little projection. This stage of the case is fre- 
quently accompanied with an itching sensation, produced by the im- 
prisonment of the hair within its follicle, the aperture being partially 
closed by the corrugated edge of the epidermis, and frequently by a 
minute operculum formed by the hardened secretion of the follicle. 
The operculum is rubbed off in the attempts of the patient to relieve 
this itching by friction or scratching, and the downy hair, before in- 
visible, becomes apparent. The newly-formed hair is for some time 
thin, dry, and slender, and lighter in color than the natural hair, but 
after a time it gains its proper thickness and hue. 

Instead of affecting the entire head, the hair sometimes falls off, 
without any premonitory symptoms, to a limited and circumscribed 
extent only [partial accidental alopecia), leaving one or more round 
patches on the scalp, of which the surface is smooth, white, and de- 
pressed. Examining the skin at this part, it is evident that the hair- 
follicles are either very much diminished in size, or in many instances 
entirely gone, particularly towards the centre of the patch, in which 
situation the scalp is obviously thinner than nearer the circumference. 
This, like general accidental alopecia of the scalp, is clearly an atrophy 
of the hair-follicles, and has had various names assigned to it by 
different authors. From presenting a regularly circumscribed disk of 
baldness, surrounded by long and unaffected hair, it has been named 
" alopecia circumscripta" and u area." When several of the patches 
run into each other, so as to present a serpentine figure, it has been 
called " ophiasis ;" but its more common designation is that which it 
received from Willan, "porrigo decalvans ;" this latter term being in- 
tended to ally it with common ringworm. 

CALVITIES. 

Syn. Atlirix cahities, Mason Good. Senile baldness. Der Kahlkopf. 

Alopecia, the natural consequence of age, is a change taking place 
gradually in the follicles, by which the formative structure, from ex- 
hausted nutrition, becomes atrophied, and the follicles obliterated. 
The change is usually preceded by dryness, and loss of color of the 
hair. But baldness of this kind is not necessarily confined to old 
persons; it is daily observed at an earlier period of life, as at forty, 
thirty, and sometimes in persons still younger. Occasionally it results 
from mental anxieties and severe afflictions; but at other times comes 
on without apparent exciting cause. 



608 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

In association with the baldness of age, it is interesting to note that 
alopecia occurs on the vertex of the head, in the situation in which 
the integument is hound down somewhat tightly upon the bones of 
the cranium, and where the circulation is least abundant and most 
likely to be interfered with. We frequently see it limited on each 
side by a line which corresponds with the parietal ridges, and poste- 
riorly by the upper margin of the posterior portion of the occipito- 
frontalis muscle, while below this line, over the temporal muscle at 
each side, and over the occipito-frontalis muscle behind, the hair still 
remains comparatively unaffected. It is obvious that in this case the 
cause of the baldness must be sought for in an impediment to circula- 
tion through the textures of the scalp of the upper part of the head; 
and in correspondence with this inference, 'we remark the exceeding 
paleness of the cranial region. But the same cause may be supposed 
to have existed also in women, unless we admit that a larger quantity 
of adipose tissue situated beneath the integument of the scalp, may 
afford more easy and unimpeded transit for the minute vessels to the 
capillary plexus of the derma. 

I am the more induced to suppose that this may be the case, from 
observing the infrequency of baldness on the pubes, where a thick 
cushion of fat is interposed between the hard parts and the surface, 
and the vessels are enabled to make their passage through a soft 
and yielding medium to their distribution in the papillary layer of the 
skin. 

The integument of the scalp of old persons who have been bald for 
some time, is remarkable for its extreme smoothness. Bichat ob- 
serves, that he examined the scalp of several bald heads by dissection, 
and he invariably found that the internal surface of the integument, 
when raised from the fat and superficial fascia, was remarkably even. 
There was no trace of the numberless appendages constituting the 
follicles of the hairs which are found in the hairy scalp. On the con- 
trary, in a man recently bald from' typhus fever, the follicles were dis- 
tinctly apparent, and contained each a minute, colorless, down-like 
hair, the rudiment of a fresh growth. Hence, he continues, there is 
this important difference between the baldness of the aged and that 
which succeeds disease ; that in the first, the whole of the secreting 
structure dies, or becomes atrophied, from the cessation of circulation 
in the vessels of the part ; whereas, in the latter, the hair alone falls, 
while the follicle remains behind. 

Bichat also remarked, that the follicles of the hair, when seen from 
the exterior, appear to become more and more shallow, until at last 
they reach the surface, and are obliterated completely. The same 
change may be observed on the surface of tumors forming in the scalp. 
The integument becomes gradually thinned, the hair-follicles becoming 
more and more shallow, until every trace of them has disappeared, and 
the hairs which they once contained fall off. 

Causes. — The proximate causes of baldness have been already 
stated ; they are, defective development of the formative organ, de- 
fective circulation in the formative organ, and defective nutrition of 
the formative organ. The remote causes are, hereditary peculiarity, 



DISEASES OF THE HAIR. 609 

the termination of acute diseases, certain diseases of the skin, certain 
general affections, syphilis, mercury, coffee taken in excess, late hours, 
extremes in venery, old age. The fall of the hair which occurs during 
convalescence from fevers and diseases attended with extreme depres- 
sion of the vital powers, must be ascribed to enfeebled vigor of the 
system and consequently to defective nutrition of the hair. Lemery 1 
mentions the case of a patient, who some months after a violent hyper- 
catharsis, lost the whole of his hair. 

The hair may suffer from any disease in which the activity of the 
nervous and vascular systems is directed energetically to any one por- 
tion of the body to the impoverishment of the rest, as in some local 
diseases. I have seen nearly the whole of the hair of the scalp lost 
during the progress of an ordinary pregnancy. In rheumatism and 
gout, the hair is liable to grow dry, and fall off. The loss of hair is 
sometimes remarkably exhibited in phthisis, 2 in which disease, not 
only the hair of the scalp, but also that of the eyebrows and beard is 
apt to fall. This change is particularly observable in young women 
possessed of extremely long hair. Instances in which alopecia is attri- 
butable to syphilis are not uncommon ; mercury, also, when taken for 
a length of time, is supposed to affect the secreting organs of the body 
injuriously, and among these, the secreting apparatus of the skin. M. 
Lagneau, in his article "Alopecia," in the Bictionnaire de Medecine, 
expresses a different opinion, as relates to the operation of mercury. 
He remarks, that it is erroneous to suppose that persons affected with 
syphilis are rendered bald by the abuse of mercury, for alopecia has 
been seen to manifest its presence, occasionally, before the patients 
have employed this remedy, or any other antisyphilitic medicine 
whatsoever. On the other hand, he continues, I do not believe that 
any one ever saw alopecia developed, after the cure of other diseases, 
by mercury. 

Baldness is modified by sex : in the male it is common, but in the 
female, rare. I am disposed to believe that the difference between 
the sexes in this respect, lies in the greater proportion of subcutaneous 
fat existing in the female. The scalp of bald persons is usually thin ; 
and eunuchs, who are generally fat, are remarkable for the length and 
permanency of their hair. 

Gustav Simon ascribes alopecia areata to the destruction of the hair 
by a vegetable fungus. I am an unbeliever in the doctrine. 

Treatment. — The principal indication to be fulfilled in the treat- 
ment of baldness, is to stimulate the capillary circulation of the scalp, 
which is evidently below the natural standard. With this view I am 
in the habit of recommending the washing of the head every morning 
with cold water, drying it by friction with a rough towel, brushing it 
with a hard hairbrush until redness is produced, and then applying 
some stimulating application, rubbed briskly into the scalp for the 
space of five minutes. In women whose long hair contraindicates the 

1 M<5m. do l'Acad. des Sciences, prem. mem. vol. ii p. 39. 

2 Hippocrates remarks, "Quibus tahe laborantibus, eapilli de capite defluunt, hi. alvi 
fluxu superveniente, moriuiitur." 

39 



tilO DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

use of the cold bath, stimulating applications with plentiful brushing 
must be relied on. From two to four drachms of the unguentum 
stimulans, 1 combined with an ounce and a half of sweet-scented poma- 
tum, form an elegant and useful compound for procuring the proper 
amount of stimulation of the scalp in alopecia. 

In addition to the trichogenous pomatum, it is sometimes convenient 
to be in possession of an agreeable stimulating wash for the hair. 
The wash may be used either alone or alternately with the pomatum. 
The best trichogenous wash, according to my experience, is the ammo- 
niated spirit wash, of which the composition will be found among the 
"selected formulae." 

Various stimulating substances have been suggested and used from 
time to time, in the treatment of alopecia, with advantageous results ; 
such as mustard, horseradish, walnut-leaves, the pomades of Dupuy- 
tren and Gibert. The pomatum ascribed to Dupuytren appears to me 
to be too clumsy a compound to owe its origin to so elevated a source ; 
this remedy, with the trichogenous ointment recommended by Gibert, 
will be found among the "selected formulae. " 

Avicenna recommends the use of leeches, slight scarification or acu- 
puncture in the first instance, followed by rubefacients. The latter 
were in high favor among the ancients, who have left a goodly list of 
them in their writings : the following are some of the principal : oils 
of chamomile, wormwood, bay, laurel, and dill ; hellebore, euphorbia, 
pomegranate, nasturtium, stavesacre, foenugreek, rosemary, sage, 
Peruvian balsam, tar, frankincense, mastich, myrrh, and laudanum. 
Laudanum is warmly praised by Dioscorides and Galen, and occupies 
a place in most of the local applications for baldness. 

It would not, however, in all cases, be judicious to limit the treat- 
ment of baldness to external remedies. Where disturbance of the 
secretive and digestive functions is present, these require attention. 
Where the energies of the nervous system are obviously reduced below 
their natural level, steel medicines and tonics may be used with advan- 
tage. 

My practice in area, after regulating the secretions, and, if neces- 
sary, administering ordinary digestive tonics, is to prescribe my ferro- 
arsenical mixture internally ; and the use locally of some moderately 
stimulating pomatum, liniment, or lotion, such as the diluted pomatum 
stimulans, an ammoniacal liniment, or a lotion of acetum cantharidis. 
With these remedies the cure is simply a question of time ; the result 
cannot be otherwise than successful. 

When the hair begins to grow after baldness, it is at first of a light 
color, dry, soft, and almost downy, like the young hair of a newly- 
born child ; but, by degrees, under favorable circumstances, it resumes 
the color and strength of the surrounding hair. At other times, this 
colorless hair remains during life, and forms a remarkable contrast 
with the dark hair of the rest of the head. The restoration of the 
hair to its primitive strength is said to be favored by shaving the 
scalp, the object of this operation being to confine the nutritive fluids 

1 Vide " selected formulas'' at the end of the volume. 



DISEASES OF THE HAIR. 611 

to the formative structure, until it shall have regained sufficient 
power to produce hair of a proper degree of size and strength. Many 
authors concur in the advantage of shaving as a means of strengthen- 
ing the hair. Fallopius upon this subject observes, " II y a quarante 
ans que nous portons la barbe longue, en signe de notre de'shonneur 
et de notre servitude ; avant cette epoque nous nous rasions et nos 
poils ne tombaient pas. Les Espagnols en envahissant l'ltalie, y ont 
introduit la tyrannie, la verole, et l'usage de la barbe longue." 

III. ABNORMAL DIRECTION OF THE HAIR. 

Under the head of abnormal direction of the hair, may be assem- 
bled two instances of irregularity in its growth and arrangement, not 
referable to the preceding groups. They are, 

Trichiasis ciliorum, 

Trichiasis coacta. 

TRICHIASIS CILIORUM. 

Trichiasis ciliorum is an irregularity in the growth and direction 
of the eyelashes. The cilia in this disorder grow inwards towards 
the surface of the eyeball, and, rubbing against the conjunctiva, give 
rise to chronic inflammation of that membrane. 

The treatment of trichiasis ciliorum consists in removing the mis- 
directed lashes by means of the ciliary forceps, and preventing their 
future growth by the application of nitrate of silver. 

TRICHIASIS COACTA. 

Felting of the hair. 

Felting is a derangement of the hair arising from neglect, and has 
no claim to consideration as a disease. It consists merely in a state 
of inextricable interlacement, best expressed in its name. Felting of 
the hair is rarely met with, and when it exists, is seen in women, 
whose long hair affords the only excuse for such a state of disorder. 
It has been observed after childbed, and in cases of extreme distress. 

IV. ALTERATION OF COLOR OF THE HAIR. 
Alteration of the color of the hair arises from disorder of the chro- 

matogenous function of the formative organ, and is very commonly 
associated with a similar alteration of the rete mucosum of the skin. 
It ie by no means rare to find a lock of hair different in color, trichosis 
decolor, from that which surrounds it. Less frequently, sudden altera- 
tions of color have been observed, while blanching of the hair, or 
canities, trichosis carta, is the natural effect of the torpor of function 
which accompanies advancing age. 

TRICHOSIS DECOLOR. 

Two instances of reproduction of hair of different color to the 
original, after recovery from severe illness, are recorded by Alibcrt ; 



612 DISEASE? OF SPECIAL STRUCTURE OF THE SKIN. 

in one of these, a head of bright red hair replaced one of dark brown, 
and in the other, hair of a deep black color took the place of brown. 
In the case of baldness from hypercatharsis, mentioned in a preced- 
ing page, the hair, originally of a brown color, was reproduced fair ; 
and gray hair has been known to fall off in advanced age, and a new 
crop, similar in color to that possessed in youth, to be substituted. 

Dr. Isoard, in a paper entitled, "Observation relative a une famille 
dont chaque individu presente plusieurs anomalies remarquables," 
in the Journal Complementaire du Diction n aire des Sciences Medi- 
cates, amongst other extraordinary physiological and pathological 
anomalies observed in the members of this family, remarks, that one 
of the daughters, seventeen years of age, and deaf and dumb from 
birth, each time that she is attacked by a fever peculiar to her con- 
stitution, undergoes a change in the color of her hair, from a pleasing 
blond to a dusky red, but that as soon as the febrile symptoms 
diminish, the natural color is restored. In the second volume of the 
Memoirs of the French Academy of Sciences, is the narrative of a 
case in which the hair of a female was changed from brown to fair 
during her confinement, which otherwise presented no remarkable 
feature. M. ViHerine" 1 relates the case of a young lady, thirteen years 
of age, who, never having suffered from any more serious illness than 
slight pains in the head, perceived, during the winter of 1817-18, her 
hair fall off in several situations, until, at the end of six months, 
there was not a single hair remaining. In January, 1819, the scalp 
began to show a new growth, of a black-colored wool, in the situa- 
tions first affected, and of brown hair over the rest of the head. The 
wool and the brown hair became white, and partly fell off after they 
had reached the length of three or four inches, while the rest changed 
their tint at a certain distance from the point, and became chestnut- 
colored for the rest of their extent towards the root. The hair had a 
singular appearance, half white and half chestnut. The specimens 
sent to the Society were mingled with a number of short hairs entirely 
chestnut-colored. In remarking on the preceding case, M. Villerme 
observes, that he has more than once seen the hair, particularly in 
phthisical patients, after having become white and fallen off, suc- 
ceeded by a crop of new hair of a darker color even than the original 
hair of the patient. The late Dr. Chaumenton presented this pheno- 
menon in a marked degree. 

Dr. Bruley, of Fontainebleau, communicated to the Society of 
Medicine in Paris, in the year 1798, the history of a woman, sixty-six 
years of age, named Castellane, whose hair, naturally white aad 
transparent as glass, became jet-black four days before her death. 
She died of phthisis. Some of this hair was transmitted to the 
Society, and was found to be quite black, with a few white hairs 
interspersed. On examination after death, Dr. Bruley found the 
bulbs of the black hair of large size, and gorged with dark pigment. 
The roots of the white hairs were dried up, and two-thirds smaller 
in size than those of the black hair. In his comments on this case, 

1 Journal Generate de Medecine, vol. lxix. p. 213. 



DISEASES OF THE HAIR. 613 

Dr. Bruley observes : " It is certain that disease may give rise to a 
change in a short period, that, according to Haller, requires a long 
period to accomplish naturally." 

TRICHOSIS CANA. 

Syn. Canities. Trichosis poliosis, Mason. Good. Der G-raukopf. 
Blanching of the hair. 

y Under the term trichosis cana, or canities, I propose to describe 
whiteness of the hair, whether its production be congenital, or depen- 
dent on age, disease, or other causes. Dr. Copland regards the term 
as applicable only to whiteness resulting from an abnormal cause; 
hence he defines it, " hairs prematurely gray, hoary, or white." Cani- 
ties presents two varieties in degree ; in the one the hair is "snowy," 
of an opaque white, and corresponds in thickness with ordinary hair; 
in the other it is clear and transparent, the " silvery hair" of age, 
assuming a yellowish tint on desiccation by the atmosphere, and not 
unfrequently finer than ordinary hair. These two kinds of hair offer 
remarkable chemical differences ; the former containing an abundance 
of calcareous salts, and the latter a much smaller quantity, or even 
none. 

Canities may be of three kinds : congenital, accidental, or senile ; 
it may also be, in either of the three groups, partial or general. 

Congenital canities of the hair is usually partial ; I have seen 
two examples in young children where the phenomenon presented 
itself in the form of round patches ; both were of the snow-white 
kind. In the one, the patch was situated on the side of the head; 
while in the other, it occupied one side of the forehead. The skin 
upon which the hair grew was remarkable for its whiteness, and con- 
fcrasted strongly with the neighboring integument. Bartholin saw 
an infant, the whole of whose hair on one side of the head was 
brilliantly white, while the opposite side was equally remarkable for 
its jetty blackness. Ridlinus and others have seen the entire head 
of young persons uniformly white, although different in appearance 
from that of old age, and approaching very slightly the tint of fair 
hair. I have before alluded to the whiteness of the hair of Albinoes, 
both of the European and African race. Rayer, in the Atlas accom- 
panjdng his work on diseases of the skin, gives a delineation, copied 
from a picture in the museum of the Jardin du Roi, of a young ne- 
gro, upon the middle of whose forehead, and rising from the root of 
the nose so as to include a moderately large patch of hair of the front 
of the head, is a broad tract of skin wholly deprived of pigment; the 
hair is perfectly white, and the white band on the forehead rendered 
the more striking, by presenting a roundish islet of deep black near 
its middle. On the same plate is a figure, representing the head of 
an Albino negress, copied from Buffon ; the skin of the face and the 
wool upon the head are entirely and completely white. Schcnkius dc- 
taile the ease of a young man, whose beard grew white on its first ap- 
pearance. 

Accidental canities and senile canities present varieties in ex- 



614 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

tent : sometimes the whiteness is partial, being intermingled with the 
ordinary hair over the entire head, and producing, according to its 
proportion, the relative shades of gray. At other times it is local, and 
confined to one or several spots, constituting so many distinct patches ; 
or it may be general, and involve the entire head of hair. It com- 
mences generally upon the temples, and thence spreads gradually over 
the rest of the head. Blanching of the hair occurs first upon the 
head : it proceeds, in the next place, to the hair of the face, and sub- 
sequently attacks the pilous covering of other parts of the body. 
When white hair falls off it is not reproduced, but the scalp beneath 
remains bald. In Europe canities would appear to be equally common 
in the male and in the female, but attacks the latter at a later period 
of life, unless induced by other causes than age. "In China," says 
Mr. Lay, " the women turn gray sooner than the men ; the former are 
often bald, the latter seldom." 

Blanching of the hair commences at the root, and the colored part 
is gradually carried onwards, further and further from the integument. 
It is curious to see the hair undergoing this change, parti-colored in 
appearance, and reminding us of the ringed hair of the gray cat and 
ichneumon. The kinds of hair most liable to the invasion of white- 
ness are those of a dark color, as black and brown ; fair and auburn 
hair rarely become gray, but are more liable to fall off. 

I have at present under my care a little girl, not yet six years of 
age, in whom there is an abundance of white hair mingled with that of 
her natural color, brown ; and there are besides many of those short, 
bent, and horny white hairs, which are common in advanced age. She 
is a pale, thin, and excitable child; and has a superadded cause of 
nervous exhaustion in a large clitoris. At her birth she possessed an 
abundance of black hair, which, although retaining its quantity, has 
gradually altered to a rich brown ; her eyebrows and eyelashes are 
still black. About twelve months back she received a shock to her 
nervous system from an accident ; and some weeks afterwards her hair 
was found to have changed to white in parts of the head. It began 
in three circular patches, and has gradually increased until the head 
has quite the appearance of that of an elderly person. There is be- 
sides some tenderness of the head, and a furfuraceous desquamation. 
The change of color of the hair in this little girl is evidently a neuro- 
pathic phenomenon. 

Causes. — Congenital canities depends upon some constitutional pe- 
culiarity inherent in the organization of the individual. Senile canities 
is the consequence of diminished powers of the cutaneous nervous sys- 
tem, as evinced, either* by the alteration of the pigment 'deposited in 
the formative cells of the hair, or by the entire absence of the color- 
ing principle. 

The remote causes which have been observed to give rise to acciden- 
tal canities are, mental emotion, physical suffering and privation, con- 
stitutional affections, disease, and injuries. Of mental emotion, as of 
grief, anxiety, fear, terror, anger, acting as exciting causes of blanch- 
ing of the hair, there are numerous recorded instances. In some of 



DISEASES OF THE HAIR. 615 

these cases, the effects were gradual, in others immediate, producing 
the silvery tints of age in the course of a few hours. 

" The different passions of the mind," says Bichat, " have a remark- 
able influence over the internal structure of the hair ; often, in a short 
period, grief effects changes in its color, blanching the hair probably 
by means of absorption of the fluids contained in its tissue. Many 
authors have recorded similar facts. Some, and Haller among the 
rest, have doubted the truth of these assertions, but I know at least 
five or six'examples, in which the loss of color was completed in less 
than eight days. In a single night, a person of my acquaintance 
became almost entirely blanched, on receiving some distressing news." 

The hair of Marie Antoinette, the wife of Louis XVI., is said to 
have become gray in a short period, from grief. The same statement 
is recorded with regard to Mary Queen of Scots. It is affirmed that 
Sir Thomas More became gray during the night preceding his execu- 
tion. Borellus asserts that two gentlemen, one a native of Languedoc, 
the other a Spaniard, were so violently affected, the first by the 
announcement of his condemnation to death, the latter by the bare 
thought of having incurred a serious punishment, that both became 
blanched in the course of a single night. Borellus adds, with regard 
to the latter gentleman, that his hair regained its natural color on being 
set at liberty. Schenkius and Boyle relate similar instances, but with- 
out the subsequent restoration. Hermeman also records an instance 
of sudden loss of color of the hair. 

Dr. Cassan, in a paper in the Archives Grfoierales de Medecine, 
before referred to, records the example of a woman, thirty-three years 
of age, who, on being summoned before the Chamber of Peers to give 
evidence upon the trial of Louvel, underwent so powerful a revulsion, 
that in the course of one night the hair was completely blanched, and 
a furfuraceous eruption appeared all over her head, on her chest, and 
on her back. After the disappearance of the eruption, the hair still 
maintained its abnormal color. 

Henry III., of Navarre, on hearing that the edict of Nemours was 
conceded, a condition favorable to the supporters of the League, was 
80 exceedingly grieved, that in the course of a few hours a part of 
one of his mustachios whitened. In a person referred to by Rayer, 
several of the cilia became blanched, accompanied with white spots 
over the arms and forearms, in consequence of mental agitation. 

M. Moreau 1 observes, " I once knew an aged man, for whom snow- 
white hair and a countenance deeply marked by the furrows of care, 
inspired t lie respect which we owe to age and misfortune." "My 
hair," said he, "was as thou seest it now long before the latter season 
of my life. More energetic in their effects than assiduous toil and 
lingering years, grief and despair at the loss of a wife most tenderly 
loved, whitened my locks in a single night. I was not thirty years 
of age. Judge, then, the force of my sufferings; I still bear them in 
frightful remembrance." 

1 Journal G6nerale de Medecine, vol. iv.. p. 280. 



H16 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

The poets make frequent reference to this remarkable and sudden 
effect of violent mental emotion : 

" O nox ! quam longa es, quae facis una senem !" 

Byron, in the "Prisoner of Chillon," refers to the same phenome- 
non: 

" My hair is gray, but not with years, 
Nor grew it white, 
In a single night, 
As men's have grown from sudden fears." 

I have myself seen several undoubted instances of blanching of the 
hair within the space of a few hours ; and have recorded some in my 
treatise on Healthy Skin ; and my researches into this subject, 
started in a skeptical spirit, and with doubt as to the possibility of 
such an occurrence, have resulted in a conviction that sudden blanch- 
ing of the hair, although rare, is nevertheless an established fact. 

After some diseases of the scalp, it sometimes happens that the 
newly-formed hair remains permanently white ; the same change is 
occasionally observed upon cicatrices left by wounds. 

V. DISEASES OF THE HAIR. 

Two diseases only come strictly under this denomination, as being 
characterized by a morbid alteration in the structure of the hair. One 
is amongst the most common of the diseases of the scalp of this 
country, namely, ringworm ; the other is a disease of Central Europe, 
and particularly of the marshy districts of Poland, the plica polonica. 
Much confusion has existed with regard to the former of these affec- 
tions, in consequence of the variety of names which have been assigned 
to it, and also from the fact of the generic title comprehending diseases 
of a totally different character. Moreover, the names themselves are 
ill chosen, the term " tinea" relating to the condition of the hair at a 
period when the disease has been in existence for some time ; while 
the term " porrigo" was selected by Willan, only because it had been 
in use among the ancient classic writers ; neither of the terms having 
any reference to the nature of the disease. Under these circum- 
stances, I consider that a first step to the proper understanding of this 
affection, and the removal of existing difficulties, might be made by 
adopting for its designation the term t?-ichonosis, or trichosis} I am 
further induced to give a preference to this term by finding it to coin- 
cide with what I believe to be the true pathological nature of the 
disease, namely, a morbid action producing degeneration and destruc- 
tion of the hairs. 

The proper diseases of the hair are, therefore — 

Trichosis furfuracea, 
Trichosis plica. 

1 Der. 6f'£, eapillus ; v6<roc, morbus. 



DISEASES OF THE HAIR. 617 



TRICHOSIS FURFURACEA. 



Syn. Common, or scurfy ringworm. Tinea capitis. Tinea nummularis. 
Porrigo furfurans. Porrigo scutulata, Willan. Porrigo circinata, 
Mason Good. Porrigo tonsoria. Pityriasis decalvans, Gibert. 
Squarra tondens. Tinea tondens, Mahon. Herpes tonsurans, Caze- 
nave. Alopecia porriginosa, Sauvages. Phy to- alopecia, Gruby. Tri- 
chophyton tonsurans ; Trichomyces tonsura?is, Malmsten. 

Common ringworm of the scalp (Plates XIV., XV.) is characterized 
by a dry and furfuraceous state of the skin, occurring in circular or 
oval patches of variable size. The patches are slightly elevated, 
papillated, 1 and spangled, or, as it were, dusted over with minute 
epidermal scales. The hairs growing on the patches are whitish, 
twisted or bent, shrivelled and brittle, in some instances broken off 
near the skin, in others, matted into conical prostrate bundles ; or, 
when augmented in thickness by an accumulation of scurf, condensed 
into thin yellowish-gray and fissured crusts. When heads affected 
with this disease are kept clean, the patches look parched, and the 
hair covering them withered and dried up. At a latter period, the 
patches are left more or less bald, but never completely so as in 
alopecia areata. 

In the early attack of common ringworm, the only appearance of 
disorder that can be detected is a thin layer of scurf, either in sepa- 
rate scales around single hairs, or in patches, including several, or a 
more considerable number. This formation is accompanied with a 
slight degree of itching, which is relieved as soon as the scurf is torn 
away by the nails or removed by the aid of the comb. At a later 
period, the skin upon which the furfuraceous scales are dusted 
appears reddish and slightly raised; the papillae next make their 
appearance on the reddened patches, and subsequently the peculiar 
alteration of the hair. 

When the disease is recent, the papillae are very conspicuous ; they 
are small and pyramidal, and resemble very closely the papillae of 
cutis anserina thickly grouped together ; they are, in fact, the mouths 
of the hair-follicles swollen and prominent from congestion, and have 
the appearance of being drawn up by the growth of the hair. The 
papillae are inclined obliquely in the direction of the hair, are some- 
what imbricated, and from the summit of each there issue one or two 
hairs surrounded by a whitish film, formed by the accreted sebaceous 
contents of the follicle. In older patches the papillae are less evident. 

The hairs in this disease have been compared, not unaptly, to "tow." 
They are remarkable for their bent and twisted shape, and resemble 
the fibres of hemp, in color, as well as in apparent texture; they are 
irregular in thickness, and are broken off at variable distances from 
the scalp, giving rise to the moth-eaten appearance from which com- 
mon ringworm derives its synonym, tinea. In dark-haired children, 
the stumps of the broken hairs frequently present little black knobs 

1 Tin' .MM. Malion liave compared this appearance to the skin of a plucked fowl; the 
papillse they term asperities. 



618 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

at the mouths of the follicles ; this is the first effort of a restorative 
process. 

The crusts which form over the morbid patches when the disease is 
neglected, are composed of furfuraceous scales and diseased hairs, 
agglutinated together by the moisture which rises from the skin ; they 
are grayish and yellowish in color, and when of large size, are apt to 
break up, in consequence of the movements of the integument, into 
several angular compartments, the line of rupture being remarkable 
for its white and silvery appearance. Moreover, on the surface of the 
crust, which is dry and harsh, the tow-like fibres of the diseased hairs 
may generally be perceived. 

The porrigo furfurans of Willan and Bateman is a medley of 
diseases mingled together in a single description; one while the 
symptoms seem referable to eczema, another while they diverge into 
pityriasis or psoriasis, and only belong to ringworm when the state of 
the hair is spoken of as partially fallen off, thin and less strong in its 
texture, and sometimes lighter in its color, than natural. The remark 
that the disease "occurs principally in adults, especially in females," 
carries the mind to those disorders of the sebiparous glands and hair- 
follicles in which the desiccated sebaceous substance collects about 
the roots of the hairs, and the latter fall off. We must therefore 
dismiss porrigo furfurans altogether from consideration. 

The description given by Willan and Bateman of porrigo scutu- 
lata, saving the pustules, which are a complication presently to be 
referred to, evidently applies to common ringworm. The character 
which principally occupied the attention of these authors in portray- 
ing the disease, was the "distinct and even distant patches of an 
irregularly circular figure," and this character forms the basis of their 
specific designation. Indeed, the term"' scutulata" in reference to 
them is not inapplicable, for the rounded and well-defined patches, 
studded over with prominent papillae, are by no means unlike the 
scuta with which they are compared. 

In the early part of its course, common ringworm is unattended 
with discharge of any kind, and sometimes this absence of secretion 
is conspicuous throughout its entire existence. At other times, and 
especially when neglected, the crusts give rise to considerable itching, 
and the attempts made to relieve this annoyance aggravate the inflam- 
mation of the skin, and occasion discharges of ichor and pus. Occa- 
sionally, as a complication of disease dependent on increased inflam- 
mation, pus forms around the apertures of the follicles, and a crop of 
small pustules is the result. Willan mistook these pustules for the 
primary form of the disease, and for that reason placed it in his group 
of " pustulae." The pustules, when they exist, are generally observed 
in the most active part of the patches, namely, along their edge, and 
in this situation I have sometimes seen them forming a double or a 
triple row. 

Common ringworm is attended with considerable itching, and the 
irritation and inflammation excited by scratching are apt to give rise 
to enlargement of the occipital and cervical lymphatic glands. These 
symptoms subside when the cutaneous inflammation is relieved. 



DISEASES OF THE HAIR. 619 

In England, the ringworm here described is one of the most frequent 
of the diseases affecting the scalp. In France, according to Raver, 
the disorder is "extremely rare; I have only," he remarks, "seen a 
single case of it in a child." 

Ringwokm OF the Body. — Common ringworm, when it attacks the 
head, is frequently seen also on the neck, arms, and other parts of the 
body. The patches of the disease in these situations are circular in 
shape; they have a reddish ground, dusted over with extremely fine, 
white, furfuraceous or farinaceous scales; are slightly elevated and 
papulated at the margin, but uniform with the surrounding skin in 
the centre. Sometimes the elevation of the margin is absent; and 
then, if the powdery scales be collected on the surface in great num- 
bers, the patches look whiter than the adjoining skin. In children 
having a brown hue of the skin the white appearance of the patches 
is not uncommon. 

The differences which common ringworm presents when viewed on 
the head and body at the same time, are easily explained, when we 
remember the dissimilarity of organization of the two regions; the 
highly-developed condition of the hair-follicles and hair of the one, 
and the smaller dimensions of those structures in the other. The 
ringworm of the body seems to have but little hold upon the skin in 
comparison. with that of the scalp, and runs along it with great rapi- 
dity. The patches spread by their margin, while their area returns 
to its healthy state; and the rings (tinea annularis) resulting from this 
mode of increase, are frequently of considerable dimensions. Some- 
times the prominent margin of one ring remains, while the disease 
propagated from its periphery throws up a second, or even a third 
ring. 

I have observed this form of ringworm on the neck or arms of adult 
females who have tended children suffering from trichosis furfuracea ; 
but as frequently on others who have had no such association. 

Pathology. — The seat of disease in common ringworm is the hair 
and the epidermal lining of the hair-follicles. 

When examined with the microscope, the dry, discolored, and fri- 
able hairs of this disease are found to be more than twice their 
natural size, and a great change is perceptible in their structure. The 
average diameter of human hair, as ascertained by a measurement of 
two thousand hairs from the heads of different persons, is ? J- C of an 
inch ; while a number of hairs growing from the morbid patches of 
common ringworm measured between 3 ^ and Ti i of an inch. 

A healthy hair is composed of three portions, a cortical portion or 
cuticle, which forms the surface; a fibrous portion, which constitutes 
the chief bulk of the hair ; and a central medullary portion or pith. 
In the diseased hair, the cortical portion is little altered from its 
normal condition, but is apt, in consequence of the morbid state of 
tlic layer immediately beneath, to crack and peel off, and so produce 
a roughness of the shaft. The medullary portion is apparently un- 
affected ; the chief pathological changes being found in the fibrous 
portion, and particularly in its external part. 



620 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

The fibrous portion of the diseased hair appears, from the great 
difference of structure which it presents, to be composed of two 
layers, an outer layer of various thickness, made up of colorless nu- 
cleated granules, and occupying about one-third the diameter of the 
shaft ; and an inner layer, which retains move or less of the normal 
fibrous structure. 

The external layer of the fibrous portion of the diseased hair is 
entirely formed of transparent, globular, nucleated granules, closely 
packed together, and constituting a tessellated structure. The size of 
the granules is about gg^o of an inch, and they are somewhat flattened 
from mutual pressure. The cohesion subsisting between the granules 
is slight, for when the cortical layer of the hair is torn and peeled off, 
some of the granules remain attached to it, and others are dislocated 
from their natural position. 

The internal layer of the fibrous portion, at the same time that it 
retains its fibrous character, is evidently altered in texture; the fibres 
are thicker than natural, they are undulated in arrangement, and 
they appear to have entering into their construction, from point to 
point, one or two, and even long rows of the nucleated granules. 
The undulated and swollen character of the fibres gives to the entire 
shaft an appearance of laxity and rottenness of texture, upon which 
the friability of the hair obviously depends. When a hair is broken 
across, the fibres give way at unequal lengths, and the ruptured ends 
look uneven and ragged. 

The epidermal lining of the hair-follicles has the same granulated 
structure as the external layer of the fibrous portion of the hair. 

In essential nature, the morbid alteration now described is a modi- 
fication of the normal structure of the hair and epidermal lining of 
the hair-follicles. In a preceding page (58), I have shown that the 
hair-fibres which enter into the construction of the great bulk of 
the hair are composed of cells, and that these latter are made up of 
granules. Now, if from any cause the granules of the hair-cells 
should undergo enlargement or hypertrophy, the state of the hairs 
will be precisely that of common ringworm ; and if the destruction of 
the natural tissue of the hair be considered, it may be described as a 
granular degeneration of the hair. 

The mode in which these nucleated granules are formed appears 
to be identical with that of the production of the analogous granules 
of favus. On the dermal surface of the epidermal lining of the 
diseased follicles I discovered corpuscles perfectly resembling favus- 
corpuscles, and I make no doubt that these corpuscles undergo the 
same changes of growth and development. There is, however, this 
difference between the two affections, namely, that in common ring- 
worm the cell-development ceases with the production of nucleated 
granules ; whereas in favus, it is driven on another stage, namely, 
to the formation of cellated and plaut-like stems. It is surprising, 
under these circumstances, that favus is so rare in comparison with 
ringworm, and that the latter does not occasionally assume the cha- 
racters of the former. 

Gruby, who has made the granules of common ringworm the sub- 
ject of examination, as well as the abnormal cell-tissues of favus, 



DISEASES OF THE HAIR. 621 

regards them in the light of vegetable formations, and places them in 
the same category as parasitic mucedinous plants, under the name of 
microsporum Audouini. The granules are, of course, sporules ; but 
where the parent plant is that produces them I am unable to tell. 
Dr. Malmsten, 1 of Stockholm, seems to adopt 2 the views of Gruby ; 
he gives the disease a new name (trichophyton tonsurans), and illus- 
trates his paper with an engraving of the appearance of one of the 
morbid hairs when seen with the microscope. 

For myself, I am as little inclined to yield the point in this disease 
as in favus ; on the contrary, the absence of the cellated shafts 
is an additional ground of argument against the vegetable theory. 
It is perfectly consistent with the pathology of abnormal nutrition, 
that the hair-granules should become enlarged, and thus be the cause 
of the subsequent changes taking place in the hair. But the hypothesis 
of vegetable growth within the substance of the hair is to me impossible 
to comprehend. 

Cause. — Common ringworm is a disease of deranged nutrition, its 
cause being debility of the organization, originating, probably, in 
defective innervation. In popular language, the disease may be said 
to depend on "poorness of blood;" and this expression conveys much 
in reference to the system of living which should be adopted for its 
cure. It must not, however, be supposed, that "living" applies only 
to food ; the other hygienic conditions, of air, exercise, ablution, and 
clothing, are equally necessary to constitute a healthful regimen. 

As an illustration of the influence of hygienic conditions in the 
production of ringworm, I may quote some remarks by Dr. Wilkin- 
son, 3 which were intended for a very different purpose. " Two families 
of fine children were brought to me from the country and put under 
my care, who had been for nearly two years affected with porrigo ; 
these cases yielded, like others, to the remedies employed, and in the 
course of two months seemed entirely subdued. One family remained 
in London three weeks after the disappearance of all complaint, yet, 
soon after their return to the country, it reappeared, and became in a 
short time as bad as ever." 

The affection is met with only in children, or, if it occur at all in 
adults, it is extremely rare. Unlike favus, it is not restricted to the 
lower classes, but is found in every of grade society, and is often more 
obstinate in the children of the noble and the wealthy than in those 
of the poor. I have been struck by its frequent occurrence in children 
born in India, and brought to this country for their education ; and it 
has appeared to me that this circumstance admitted of explanation, by 
supposing that their systems had been relaxed and weakened by a hot 
climate, and that they were consequently unable to resist the morbid 
effects of the cold of England. 

Another predisposing cause of the disease is improper food, and this 

1 Trichophyton Tonsurans, I farskarande mogel. Stockholm, 1845. 

2 I am obliged to speak hesitatingly on this point, foi although 1 have Dr. Malmeten's 

paper before me, I am not sufficiently master of the Swedish language to make out his 
opinion. 

3 Remarks on Cutaneous Diseases. By J. H. Wilkinson, 1822. 



622 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

is the cause which is most active in public schools and large establish- 
ments of children. I have sometimes had occasion to regard the 
prolonged use of an exclusively vegetable diet as the cause of the 
affection, and am convinced that a milk diet, continued for a long 
time without change, will give rise to the disease. 

The restraints of mobility and amusement, to which children are 
subjected in schools, is another and frequent cause of ringworm. 
Confined in ill-ventilated rooms, congregated in considerable num- 
bers, bending their little minds to distasteful labor, commencing their 
studies the instant they have swallowed their meals, and kept to their 
books for several successive hours in the day, it cannot be matter of 
surprise that the nutritive functions of the body should suffer, and 
that derangement of one of the simpler processes of the economy 
should be the consequence. Under such circumstances, the disease 
will probably be endemic, and the greater part of the children of a 
large school might be consentaneously or successively attacked. 

Is ringworm contagious ? I believe that it is not. Nothing that I 
have hitherto seen, and I have watched the disease with care, has 
satisfied my mind with regard to its imputed communicability. The 
observation of a great number of children in the St. Pancras work- 
house, as well as in private practice, leads me to an opposite con- 
clusion, and this conclusion seems confirmed by the pathology of the 
disease. 

Those who consider ringworm to be contagious, look upon it as a 
local affection, engendering a kind of poison, which is conveyed to 
another by means of combs, brushes, caps, or towels. The advocates 
of the vegetable theory do not hesitate to assert, that the nucleated 
granules are the seeds of the disease. Such a supposition appears to 
me to be highly unphilosophical, and indeed, unwarranted by a more 
correct comprehension of the nature of those bodies. 

If there be a poison, it must be more subtle in its nature than these 
nucleated granules, and capable, like other contagious principles, of 
poisoning the entire circulation of the patient ; for the disease 
undoubtedly lies in the constitution, and is to be eradicated more by 
constitutional than by local means. In fact, ringworm IS NOT A 
local disease, but one which pervades the entire economy, the 
local disorder being simply the effect of the constitutional disturbance, 
such as a multitude of causes capable of deranging health might 
occasion. 

It is stated that ringworm has not been known as a disease affect- 
ing the middle and higher ranks of society more than fifty years, 
although it has existed for centuries among the poor. If this be 
true, it is a fair argument against its contagiousness, unless, indeed, 
it can be shown that the laws of life and organization are different in 
the plebeian and in the patrician ; that the rich and ruddy stream of 
the latter repels a poison engendered in the troubled puddle of the 
former. But that such is not the case is proved by the fact that the 
noble and the wealthy are now as liable to the disease as the poor. 
Dr. Wilkinson, in suggesting a probable reason for the outbreak of 
the disorder among the better classes, observes : " Of all the various 



DISEASES OF THE HAIR. 623 

conjectures formed upon this subject, perhaps the most plausible is, 
that the number of children sent from the East and West Indies for 
their education has been, during the 'period referred to,' very much 
increased, many of whom bringing the disease with them, introduced 
it to the schools, and spread it rapidly through the island." Few of 
my readers will, I think, be inclined to admit this explanation as cor- 
rect, but it corroborates the observation which I have myself made of 
the liability of European children, born in a warm climate, to this dis- 
ease, when transferred to England. 

The same author, in another page of his work, observes: " As some 
of the profession doubt whether the porrigo can be produced in any 
other way than by contact, I have paid particular attention to this 
point, and I am convinced that some children are capable of generating 
the disease." 

" Four children were brought to me who had never been out of 
their parents' house but in their carriage, never had any other chil- 
dren to visit them, and never visited any ; in short, the mother in- 
formed me that they were so strictly particular on this point, that 
they never suffered the servants who attended upon the children to 
have any communication with others. One of these children gene- 
rated the porrigo furfurans ; and between two and three weeks after 
communicated the scutulata to two of the others, and the decalvans to 
the fourth." 

Can anything be more clear than that the predisposing cause of the 
disease in the above instance was the artificial physical education and 
mischievous restrictions to which the poor children were subjected? 
Dr. Wilkinson admits that the disease was generated in one of the 
children ; but it may be asked : If so, why not in all ? Why should a 
disease generated in one, be transmitted in the rest ? The answer is 
obvious: Because Dr. Wilkinson was prejudiced in favor of the theory 
of contagion. The reader may be reminded, also, in reference to this 
case, that porrigo furfurans and porrigo scutulata are the same disease, 
and that porrigo decalvans originates in the same causes which give 
rise to ringworm. 

Dr. Wilkinson further observes: "I have had several other cases 
where I had as much reason to believe that the children generated it ; 
one was a child of only three months old, who had never been, since 
her birth, in more than one room." Thus it will be seen that the too 
great care of parents in regard of their offspring is frequently attended 
Vfith the same results as extreme neglect. An important rule of con- 
duct, in the management of children, may be deduced from this ob- 
servation. 

In reference to a case already mentioned, in which the disease was 
cured in London, and remained so for three weeks, but reappeared as 
BOOH us the patient returned to the country, Dr. Wilkinson remarks: 
" During the last three weeks spent in town, as nothing was used 
to prevent the disease from reappearing, and as it is a contagious and 
active fluid, how is its action suspended for such a length of time? and 
where does it lurk ? since its whole action in two or three of the va- 
rieties seems confined to the cutis and the cuticle. I can account for 



624 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

this in no other way than by concluding that the patient generates the 
disease, for in such way, of course, however completely it may be 
banished from the surface, it may be regenerated, unless the habit of 
body or the secretions be entirely altered." 

Another author, Dr. Walter Dick, in an excellent treatise on the 
"different forms of porrigo," observes: "We have seen ringworm at- 
tacking two or three subjects in the same family, almost at the same 
time, when the occurrence of the disease could not be traced to conta- 
gion. We have been led to believe that the disease, under these cir- 
cumstances, originates from some article of food being of bad quality." 
And again: "From what we have observed, we are inclined to think 
that porrigo is not so contagious as many suppose." 

The only circumstance which has at all tended to shake my opinion 
of the non-contagiousness of ringworm, is that of the occurrence of 
patches, apparently of this disease, on the neck or arms of adult 
females who have had the care of diseased children. These patches 
never exceed three or four in number ; usually there is one only. I 
have never seen them on the scalp; they are easily cured; or soon- 
get well, if left to themselves ; and they are not uncommonly met with 
in those who have not been within reach of children affected with 
ringworm. 

But it must be remembered always, that ringworm is undoubtedly 
epidemic, and may be endemic; and this fact will serve to explain 
much that has heretofore been attributed to the action of contagion. 
In my medical practice I often pass many weeks without seeing an 
instance of ringworm ; suddenly a case comes before me, and then I 
know that I shall have a succession of such cases, not from one lo- 
cality, but from many ; an epidemic has begun and will continue for 
some weeks. In this way an epidemic seizes upon a school, and its 
progress is regarded as a proof of contagion ; I can only see in it a 
morbific atmosphere operating on constitutions predisposed to such dis- 
order, in consequence of unhealthy nutrition. A curious evidence of 
the epidemic nature of ringworm came before me accidentally a short 
time back. A brother and sister, of ten or twelve years of age, were 
both seized with ringworm at the same time, the one being in Corn- 
wall, the other in Essex ; they had had no communication with each 
other for twelve months. An epidemic of ringworm was then prevail- 
ing; but had these children been together within three months of the 
attack, every old woman in the empire would have exclaimed "conta- 
gion !" and commenced speculating upon the probable period of latency 
of the poison; or, according to the modern trichophytic heresy, upon 
the length of time that the sporules of the trichophyton maintain their 
vitality and their aptitude for germination. 

Treatment. — The indications for the treatment of common ringworm 
are, firstly, to restore the defective powers of the constitution; and, 
secondly, to restore the local power of the skin. These objects are to 
be fulfilled by similar means ; the first indication calling for improved 
hygienic conditions, improved diet, and tonic alterative medicines; the 
second requiring stimulating applications. 

The importance of the hygienic principles, air, exercise, clothing, 



DISEASES OF THE HAIR. 625 

and ablution, cannot be too strongly urged in common ringworm. 
When the disorder first appears upon the head at school, the child 
should be immediately removed, either to a more airy locality, or to 
the sea-side. I have seen several cases in which the disease has been 
entirely cured by change of air, seconded by a better assorted diet, 
and by a local application of the simplest kind. 

It is much to be regretted that some provision is not made, by those 
who have the care of the education of youth, for supplying the 
means of instruction to children laboring under this complaint ; for 
combining, in fact, physical education with mental education, and the 
advantages of sanitary regulations with both. I am quite ready to 
admit the necessity of separating boys afflicted with this disorder from 
others ; not, however, from any apprehension of contagion, or with a 
view of protection to the latter, but that the diseased youths may be 
placed under a training better adapted for their cure. Nevertheless, 
it is painful to reflect that this isolation is generally accompanied with 
a neglect of education, with a loss of months and years wholly unneces- 
sary, and yet which may never be repaired ; in some instances, indeed, 
amounting to the positive destruction of a boy's prospects in life. 

I would suggest as a remedy for this evil, that a school-sanatorium, 
especially calculated for this object, should be established in some 
healthy locality, and that the boys assembled in such a school should 
pursue their studies undisturbed, while the medical discipline necessary 
for their cure was enforced. 

The masters engaged at such a' school would be free from any dan- 
ger of contagion. Indeed, adults are not liable to take the disease 
under any circumstances. Neither must it be supposed that the assem- 
blage of affected children would be either detrimental to themselves 
or to those about them. 

In speaking of the cause of this disease, I mentioned, as tending to 
predispose to the complaint, improper diet. I remarked that I had 
seen cases in which I believed I could trace the origin of the disorder 
to a too exclusively vegetable or milk diet, and these are circum- 
stances to be borne in mind in regulating the regimen of our patients. 
I should give a preference to a sound animal diet, with a good beer, 
such as brewer's porter, 1 for drink, and chocolate, cocoa, and tea, in 
small quantity, for the morning and after-dinner meal. Butter I look 
upon as highly useful. With a sound diet and normal assimilative 
power there can be no ringworm. 

The medicines which are best adapted for the disease are the citrate, 
acetate, or hydrochlorate of iron ; iodide of iron ; iron with quinine ; 
nitro-muriatic acid, cither alone or with the tincture of cinchona or 
gentian. 

The general functions of -the body will require to be regulated in 
the usual way; but aperients and purgatives arc to be used sparingly, 
ami with care. As a laxative, there is none better than the confection 
of senna with sulphur and cream of tartar. If there be enlargement 
of lymphatic glands, having a scrofulous origin, the oleum jecoris 

1 In contradistinction to publican"s porter. 
40 



H26 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

aselli is to be had recourse to, and if there be any want of solidity in 
the bones, lime-water. 

In common ringworm, which is not neglected, there are no crusts to 
be removed ; but should there be any collection of this kind, they are 
best cleared away with water and soap, after being softened by a poul- 
tice, with the moist compress and oiled silk, or by means of a piece of 
Alison's prepared corium. 

Shaving the head is a practice which I rarely have recourse to, nor 
do I think the advantage which it holds out at all commensurate with 
its evils. If the hair be moderately short, the head may be washed 
and kept in proper order, and nothing more than this is required. I 
do not think that, as a general rule, shaving strengthens the hair. 
Some time since, while engaged in investigating the structure and 
phenomena of hair, I compared the hair of persons who had been 
shaved, with that of others in whom that operation had not been per- 
formed, and I found no difference between them. 

Washing with soap and water, followed by combing with a small- 
tooth comb, is attended with advantage; the latter process serving to 
clear away the diseased hairs sufficiently. I have already said that I 
do not consider these hairs as irritants of the skin, and tending to 
keep up inflammation, and therefore I am not inclined to join with 
Plunibe in suggesting ingenious contrivances for getting rid of them. 
As respects the soap to be recommended in this disease, there is none 
better than the old-fashioned common yellow soap, a soap of the finest 
manufacture, but at present out of favor with housewives on account 
of its color: the substitute, a lighter-colored soap, is, however, very 
inferior. Soft soap has been much in use for washing heads affected 
with ringworm, but is offensive and disagreeable, and in nowise 
superior to the soda-soaps ; indeed, I regard it as inferior to the 
common yellow soap. 

When the patches are free from their crusts and loosened hairs, I 
commence the local treatment by pencilling them with acetum can- 
tharidis, or the acidum aceticum fortius, and then anointing the 
surface with ceratum simplex cum liquore plumbi (5j ad §j). This 
application I repeat once in the week ; and on the intermediate days, 
as soon as the irritation caused by the acid has subsided, I prescribe 
a moderately stimulating ointment, such as the unguentum hydrargyri 
nitratis, or unguentum hydrargyri nitrico oxydi, diluted one-half 
with the ceratum simplex. Another ointment, which I have found 
of service, is one composed of sulphate of zinc and ceratum simplex 
(5j ad Sj); and I have also obtained good results from the unguentum 
sulphuris compositum. 

A remedy which I have found useful in common ringworm is the 
linimentum ammoniae, accommodating the. proportion of alkali to the 
amount of stimulation which it is desired to effect. Another excellent 
remedy is the oleum crotonis tiglii, twenty drops to the ounce of 
unguentum florium sambuci, or unguentum cetacei. The iodide of 
sulphur ointment, which I have frequently used, I find inferior to the 
above remedies. 

As the principle of local management of this complaint is cleanli- 



DISEASES OF THE HAIR. 627 

ness and moderate stimulation, many additional remedies might be 
mentioned as applicable to its treatment. Dr. Hamilton recommends 
an ointment of cocculus indicus, for which picrotoxine might be 
conveniently substituted. Bateman recommends the unguentum 
gallarum. Then there is the iodide of sulphur ointment (gr. x — xxx 
ad Sj)- But a better remedy than either of these, though somewhat 
objectionable in private practice, from its dirtiness and bad odor, is 
a sulphur and tar ointment, 1 originally suggested, I believe, by Dr. 
Wilkinson. v 

Dr. Walter Dick, in his Treatise on Porrigo, recommends for 
ringworm an ointment of subnitrate of bismuth (5j ad Sj), to be 
rubbed into the diseased parts, night and morning, after washing. 
The same author refers to another remedy once in high repute for 
this complaint, an ointment of oleum laurini, sulphur and camphor. 
Other remedies, which have been from time to time in vogue, are, 
sulphur ointment and soft soap, equal parts ; the unguentum sabinse ; 
and spirits of turpentine ; adhesive plaster has also come in for its 
share of praise. 

Plumbe was in the habit of pencilling the patches with strong 
sulphuric acid, taking care to wash it off as soon as smarting com- 
menced ; his subsequent treatment was simple washing. He was also 
an advocate for shaving the head. In old-standing cases where 
secondary changes had occurred, such as the formation of pustules, 
and suppuration of the hair-follicles, he preferred that the hair should 
be cut with scissors, but as short as possible, and he recommended 
that every hair contained in a follicle in which suppuration existed 
should be drawn out with the forceps. This is a needless operation ; 
and, indeed, the supposed irritative property attributed by Plumbe to 
the hairs, the apology for the calotte, is altogether unfounded. On the 
whole, Plumbe's treatment is unworthy his reputation. 

Ointments are undoubtedly better adapted for ringworm than 
lotions ; but if any insuperable objection should be made to their use, 
a lotion of sulphuret of potass (5j ad Oj) ; sulphate of zinc, in rose- 
water (588 — 5ij ad Oj) ; or bichloride of mercury, in emulsion of bitter 
almonds (gr. x ad Oss) ; might be prescribed. In this case, however, 
the consequent dryness of the skin should be corrected by cold cream 
or some simple pomatum. 

After the cure of ringworm there commonly remains for some 
time, as a consequence of debility of the skin, a dry and scurfy state 
of the scalp. The best treatment for relieving this is to dip the head 
every morning in cold water, and after drying it thoroughly, to 
anoint the skin well with some simple pomatum; or, where dipping 
the head in cold water may be objectionable, the scalp should be 
sponged every morning, while brushing, with the lotion of borax and 
almond oil. 

1 Vide "Selected Prescriptions." 



628 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

TRICHOSIS PLICA. 
Plica polonica, or Polish ringworm. 

Plica polonica, so far as I am able to judge from the description of 
the disease given by authors, is, in essential nature, analogous to the 
common ringworm of this country. There exists in it, as well as in 
ringworm, an enlargement of the diseased hairs, a condition probably 
depending on the larger size of the nucleated granules ; and the latter 
are the depositories of the morbid fluids, which are found in such 
quantities in that affection. In other words, plica is a state of granu- 
lar degeneration of the hair, the granules being turgid with a viscous 
sanguineous fluid. The state of matting of the hair, which is thought 
to be peculiar to plica, has its analogue also in ringworm ; and the 
conical bundles of which I have spoken, when describing the latter, are 
the representatives of the greater and more complete fasciculation of 
the Polish disease. 

According to the best authors on plica polonica, the scalp is inflamed 
and excessively tender ; the hairs are swollen and imperfectly formed ; 
they are tinged with a viscous and reddish-colored fluid, and the hair- 
follicles secrete an abundance of this fluid, which agglutinates the 
hairs, and then by desiccation unites them into a solid mass. The 
tenderness of the scalp in these cases is so excessive, that the bare 
touch of a single hair excites pain, and, when cut across, the reddish 
fluid with which the hairs are surcharged oozes from the divided 
extremity. This appearance, together with their extreme sensibility, 
has given rise to the supposition of the hairs being sarcofied, and per- 
vaded with vessels and nerves. The odor arising from a scalp so 
affected is described as being exceedingly disgusting ; excoriations of 
considerable extent are frequently formed, and the matted hair becomes 
the resort of swarms of pediculi. 

Plica is not confined to the scalp, but affects the hair on every region 
of the body ; the nails of the fingers and toes are also changed, becom- 
ing rough, fibrous, and discolored. Left to itself, the disease lasts for 
ten or twelve months ; the symptoms then subside gradually ; the hair 
returns to its natural diameter; and the filthy mass is pushed by 
degrees further and further from the surface, until it falls off spontane- 
ously, or is cut away by scissors. 

The hair presents some modifications, in the manner of its matting, 
which bear relation to its length. Thus, in males, who wear the hair 
short, numerous locks are matted separately, constituting the variety 
known as plica multiformis ; at other times, the matted hair forms a 
single coil, plica caudiformis ; or, again, it may constitute a large and 
irregular mass without order in its matting, the usual character of the 
disease in women. 

Several authors have asserted, that, in the majority of cases, the 
scalp is not affected in plica, and that the alteration in the hair occurs 
at a certain distance from the integument. This assertion is incredible, 
and it seems more reasonable to conclude, that in the cases adduced 
in support of this statement, the disease was advancing towards cure, 



DISEASES OF THE HAIR. 629 

and consequently that the morbid mass of hair was removed by growth 
from the surface of the scalp. A recent writer on this subject, Dr. 
Bidder, 1 makes the following remarks : " During the past summer I 
remained for several weeks in a country where plica polonica is fre- 
quent. The disease occurred only in a mild form. In all the cases 
which I examined, about twenty in number, I found the hair, for a 
distance varying from half an inch to one inch from the scalp, per- 
fectly natural ; one would have believed that the disease had been 
removed from the head by the growth of the hair. The scalp was 
perfectly normal, being neither reddened, swollen, nor increased in 
sensibility, so that disease of the hair would appear to be capable of 
existing independently of disorder of the scalp in which the matrix is 
imbedded. 

" I had also an opportunity of observing the process of separation 
of the diseased from the sound hair. Two individuals presented them- 
selves in whom the morbid mass had fallen by spontaneous separation, 
a rare occurrence. Once alive to the possibility of such a process, I 
soon discovered, in two cases, a! groove, as though made by a ligature, 
around the cylinder of the hair, and forming a perfect line of demar- 
cation between the healthy and diseased portion. In some hairs, the 
groove resembled a mere crack ; in others, it had proceeded so far that 
the separation was nearly effected. In other cases, I was unable to 
discover the line of demarcation." 

Causes. — Supposing my opinion to be correct with regard to the 
nature of plica polonica, its causes will probably be found to be analo- 
gous to those of ringworm. The disorder is most prevalent on the 
banks of rivers and in the marshy districts of Poland, in which it ap- 
pears to be endemic. It is met with, as is ringAvorm, among the noble 2 
and the wealthy, as well as in the poor ; and, unlike ringworm, it oc- 
curs in adults as well as in children. 

Treatment. — The treatment which is applicable to ringworm I 
should conceive to be suited also to plica. Change of air, improved 
diet, and altered hygienic conditions must be indubitably necessary, 
and the same tonic alterative medicines, particularly the ferro-arseni- 
cal remedies. A prejudice seems to prevail in Poland against the re- 
moval of the mass by mechanical means, which I am inclined to think 
unreasonable. It would be necessary to subdue local inflammation 
in the first instance, and afterwards apply moderately strong stimu- 
lating local remedies. 

VI. DISEASES OF THE HAIR-FOLLICLES. 

The hair-follicles and hairs are so intimately allied, that it is diffi- 
cult to understand how disease can be present in one without at the 
same time involving the other. Practically, this difficulty is solved by 
the fact thai the follicles maybe deranged in their function without 
any alteration being manifested in the structure of the hair. But the 

1 Miiller's Archiv., 1840. 

2 In one instance, I saw a mass of matted hair which had been cast from the head of a 
Polish lady of noble birth. 



630 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

reverse of this proposition is not equally true ; for in that greater 
morbid change, which is the cause of alteration in the structure of the 
hair, the follicles suffer to a greater or less extent. Hence, while the 
designation " diseases of the hair- follicles" must be regarded as apply- 
ing solely to those organs, "diseases of the hairs" may be supposed 
to implicate the follicles also. 

Disease of the hair-follicles manifests itself either as a simple erythe- 
ma or chronic inflammation ; as an erythema attended with excessive 
formation and alteration of secretion, constituting stearrhcea folliculo- 
rum ; as a suppurative inflammation of the follicles of the scalp, or 
8call ; as a suppurative inflammation of the hair-follicles of the face, 
sycosis ; and as a chronic inflammation attended with the formation of 
a peculiar morbid product, namely, favus. In a tabular arrangement, 
they would stand as follows : 

Erythema folliculorum, 
Stearrhcea folliculorum, 
9 Inflammatio folliculorum suppurans, 
Sycosis, 
Favus. 



ERYTHEMA FOLLICULORUM. 

Inflammation of the hair-follicles is indicated by an erythematous 
blush of redness of the skin, dryness, and the production of a large 
quantity of furfuraceous scales. There is, besides, considerable itch- 
ing, and more or less decadence of the hair. This condition of the 
follicles is not unfrequently the forerunner of a morbid secretion 
(stearrhoea folliculorum), which is diffused and hardens upon the sur- 
face of the scalp. The following is an example of the disease : 

A naval medical officer, while serving in the West Indies in 1833, 
suffered from an attack of erythematous patches on the crown of the 
head. They were attended with itching, and by a copious furfura- 
ceous desquamation, the itching being much increased at night. In 
1837, on his return to England, the disease presented occasional ex- 
acerbations, but never at any time disappeared entirely. In 1838, 
while on the Pacific coast of South America, frequently exposed to a 
tropical sun, and undergoing considerable fatigue with copious perspi- 
rations, the patches coalesced, and poured out " an unctuous exudation 
of a dark reddish color." At this time, also, the loosening and fall 
of the hair, which has continued until the present time, was first no- 
ticed. "Previous to my return to England in 1839," this gentleman 
observes, "large sebaceous incrustations covered the crown of the head 
in patches varying from the size of a sixpence to a shilling; the 
scales became thicker, attended with an exceedingly disagreeable feel- 
ing of heat and itching. They were in a state of continual decadence 
and renovation. I had my head shaved for two or three months, and 
while the hair remained short, I was effectually relieved from the dis- 
ease." 

As soon as the hair was allowed to grow, the disease returned, and 
in 1840, while stationed at the river Plata, he was again shaved, and 



DISEASES OF THE HAIR. 631 

continued the practice for four months. In 1841, whilst in China, he 
had recourse to shaving for the third time. " During our operations," 
he remarks, " in the Yeang-tse-keang, the heat was most intense, the 
thermometer ranging from 90° to 95° in the shade. I think the 
disease, at this time, attained its greatest pitch of intensity, which I 
am induced to attribute to the impaired state of the digestive func- 
tions, as I was confined for months exclusively to the ship, and of 
course debarred all suitable exercise. The scales at this time assumed 
a gummy character, tenacious and soft; the itching was particularly 
annoying, but was somewhat relieved. I passed eighteen months on 
the East India station without any alteration in the character of the 
complaint." 

" During my stay in England, in the winter of 1844-45, I tried 
preparations of the nitrate of silver, iodine, dilute hydrocyanic acid, 
and I persevered in the use of the tincture of iodine, applied locally, 
during the voyage to Van Diemen's Land last year without any 
benefit : and during my return I used most assiduously the bichloride 
of mercury, which relieved the itching for a short time#" 

"I am unable to account for the commencement of the disease, nor 
was I, during its progress, sensible that climate produced any material 
alteration in its character. Heat and itching were the usual concomi- 
tants, and they were at times so annoying that I was obliged to apply 
soap and water frequently during the day, which always afforded me 
temporary relief. Stimulants always increased the itching. 

" A deceased brother was similarly affected, but he never lost his 
hair, and I am the only one of my family who has felt its decadence, 
although many of my progenitors have lived to a very old age." 

"Notwithstanding the different remedies resorted to, the disease 
assumed that inveterate form which you saw when I had first the 
pleasure of consulting you in February last. Since I have been under 
your treatment, the disease has gradually yielded to the means you 
have employed. The patches, after your second application, sunk to 
the level of the surrounding integument, the squamse have not been 
reproduced to a hundredth part the extent that they were before, the 
few remaining patches have gradually lost their hardness and redness, 
and are now resuming the character of healthy integument. I feel 
that the hair has been in a slight degree reproduced." 

Besides attacking the head, erythema folliculorum is also met with 
on the forehead and eyebrows, and on the shoulders and backs of the 
upper arms. Its characters are a punctated redness with dryness of 
surface, and a roughness, which is partly due to the prominence of 
the pores, as in cutis anserina, and partly to the follicles being filled, 
and, as it were, choked up with dry and harsh epithelial contents. I 
have commonly observed this disorder in young ladies ; it injures the 
beauty of the skin, and when it attacks the eyebrows (erythema folli- 
culorum supcrcilii) is more serious in its consequences, as it causes 
the fall of the hair, and produces a papillated baldness more particu- 
larly of the outer half of the eyebrow. The absence of the natural 
sebaceous secretion of the skin, and the production of a dry sordes in 
its place, exhibits a torpor of function which is at the root of this 



632 DISEASES OF SPECIAL STRUCTURE OF THE SKIX. 

complaint. It is best treated, locally, by daily ablutions with the 
juniper tar soap, and "with the compound hypochloride of sulphur 
ointment ; and, constitutionally, by general tonics and some of the 
milder preparations of arsenic. 

STEARRHffiA FOLLICULORUM. 

Seborrhea. 

In some instances, the inflammation of the follicles is so slight as 
to escape attention altogether ; and the disease does not come uuder 
the attention of the surgeon until the altered secretion has been 
poured out upon the skin, and forms a concretion of variable thick- 
ness and extent. To this stage of the complaint I have assigned the 
name of stearrhosa folliculorum. The crust presents some variety in 
point of color. It is often yellowish, and resembles the film which 
drying-oil leaves after desiccation, and sometimes is grayish and 
greenish in its hue.- Occasionally, this state of the scalp is associated 
with dryness of the skin, and then the hair is dusty and sordid ; but, 
more frequently, there is no such appearance. 

The symptoms by which the patient discovers the presence of 
disease are, itching, frequent, often intense, sometimes constant, and 
fall of the hair. 

There is another state of the scalp, narcosis folliculorum, depending 
on chronic inflammation of the hair-follicles, which is far from being 
uncommon, particularly in women and children. In this disorder, 
the scalp and hairs are found covered with a yellowish and dirty- 
looking powder, composed of an admixture of granular particles and 
furfuraceous scales. Masses of this granular substance are collected 
at the mouths of the follicles, while others are threaded like beads 
upon the hairs. By brushing, the skin may be completely cleansed 
of this pulverulent substance, but the granular particles still remain 
threaded on the hairs, and adherent to them, at the mouths of the 
follicles. If a hair be -withdrawn, its follicular portion will be seen 
to be inclosed in a small sheath of desiccated epithelium or sebaceous 
substance, which extends almost to its root. Moreover, the root is 
slender and dry, and the entire hair looks parched and starved. 

The symptoms which denote the existence of this complaint to the 
sufferer are, the difficulty of cleansing the hair, a moderate degree of 
itching, and the fall of the hair, which comes off in large quantity. 
The fall of the hair is easily explained ; the torpidity of action, which 
gives rise to the production of a dry, sebaceous matter, and a dry and 
pulverulent epithelium folliculi, extends its influence to the growing 
hair, which is deprived of its moisture and of its hold upon the skin, 
and therefore falls before the slightest force. Another change 
depending on the same cause is not unfrequently observed in this 
disease, namely, grayness of the hair. 

When torpor of the follicles occurs upon the general surface of the 
body, it interferes, more or less, with the growth of the hairs, and is 
termed morbus pilai'is. In this affection, the hairs become imprisoned 
within the follicles by the formation, at the mouth of the latter, of a 



DISEASES OF THE HAIR. 633 

small mass or film of hardened, sebaceous matter; and, as the hairs 
continue to grow, in spite of this impediment, they are gradually 
twisted into a spiral coil (Plate VI. , fig. 10), which may be seen at 
the mouths of the follicles. A number of little pimply elevations 
are in this manner produced, each elevation corresponding with a 
coiled hair ; and if the apex of the pimples be rubbed off, the twisted 
hair will be at once exposed. This disorder is most frequently per- 
ceived on the legs and thighs. Turner remarks, that in children it 
is often met with on the back. It is attended with itching, and occa- 
sionally with acute, lancinating pains, comparable to the piercing of 
the skin with a sharp needle. 

Treatment. — The treatment of the three preceding forms of disease 
consists in the employment of moderately stimulant remedies locally ; 
and for the most part tonic medicines constitutionally. Of course, the 
common indications of disorder of stomach, kidneys, or uterine func- 
tion will not be passed over. In the case of .the naval surgeon reported 
above, I found it necessary to modify the action of the skin by blister- 
ing t,he surface occasionally with the acetum canthariilis, and after- 
wards employing the pomatum stimulans. Indeed, the latter prepara- 
tion I find invaluable in this class of diseases ; it should be sufficiently 
strong to keep up a moderate action in the skin. Another excellent 
remedy is the emulsion of ammonia and olive oil. In some instances 
a stimulating lotion may be preferred to oleaginous remedies, but, in 
the latter case, the skin must be kept moistened with cold cream or 
some simple pomatum. 

INFLAMMATIO FOLLICULORUM SUPPURANS. 
Scalled head. 

Scalled head is a disease of young persons, extending in its range 
of period from childhood to puberty. The first symptom of its attack 
is a slight itching of the scalp ; on the irritable spot a thin whitish 
crust is produced, and, after the lapse of a few days, rarely longer than 
a week, the inflamed spot, which is exactly circular, and of a size 
varying from that of a sixpence to a crown-piece, or even the palm of 
the hand, is swollen, and tender, and commonly bare, from the sudden 
and unobserved fall of the hair. The inflamed surface is red, tender, 
swollen, more or less puffed, and studded over with whitish yellow 
points, the acliore% of Willan, these yellow points being the mouths 
of the follicles distended with pus ; while the skin between the aper- 
tures of the follicles is red and glazed, and resembles the pulp of a ripe 
Strawberry. The seal] is remarkable for the suddenness of its appear- 
ance, and. for the rapidity of its progress ; in a few days it is often 
swollen to the height of three-quarters of an inch ; and seems as if 
infiltrated with pus, of which the follicles arc the openings of exit. 

The copious exudation of pus from the inflamed skin, not unfre- 
quently produces a matting of the hair over the diseased surface ; and 
disguises the morbid action taking place in the skin ; and the morbid 
structure is so tender as to render the removal of this matted coating 
an operation of some difficulty. The inflammation sometimes extends 
to the surrounding skin; and the occipital, and auricular, and even 



634 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

the cervical lymphatic glands, become tender and inflamed, and often 
suppurate. When the scall is of large size it may be solitary; but 
usually there are several dispersed over the head. 

When the suppurative action is on the decline, a dirty yellowish 
crust is formed over the diseased patch, and, on the fall of this crust, 
the skin is left bald, and of a deep red color ; the redness being 
greatest in the centre, and being slow to disperse. When the deep 
textures of the skin are much disorganized, the hair is not reproduced, 
but commonly the hair begins to grow in a few weeks after the fall of 
the scab ; and the new hair is acutely pointed like young hair. 

The diagnostic characters of scall are : the rapidity of its progress, 
its exactly circular form, the extreme swelling, tenderness, and copi- 
ous suppuration, and the sudden and complete fall of the hair. The 
medical man is not unfrequently tempted to puncture the swelling 
with his lancet, under the expectation of finding a collection of pus, 
but in this expectation he is commonly disappointed; and, in bad cases, 
the inflammation and suppurative action seem to extend even to the 
periosteum. 

Treatment. — The local treatment of suppurative inflammation of 
the scalp, is the maintenance of water-dressing or poultices, until the 
inflammation is subdued; and then the application of a mild ointment, 
such as the benzoated ointment of oxide of zinc ; or, the red precipi- 
tate ointment diluted in the proportion of one part to three of the 
diluting medium. The general or constitutional treatment must be 
essentially tonic and nutritive ; a substantial meat diet, with malt 
liquor, aided by iron, quinine, and in chronic cases by arsenic. The 
ferro-arsenical mixture answers admirably in cases of scalled head. 

SYCOSIS. 
Syn. Phyma sycosis, Mason Good. Mentagra. Ficous phyma. 

Sycosis (Plate XIV., i) is a chronic inflammation of the cutaneous 
textures, somewhat resembling acne, but limited to the hairy parts 
of the face, the chin, upper lip, submaxillary region, region of the 
whiskers, eyebrows, and sometimes the nape of the neck. The disease 
involves the hair-follicles and their immediately related tissues, giving 
rise to conical elevations, which become pustular at their apices, and 
are each traversed by the shaft of a hair. The pustules of sycosis are 
of a pale yellowish color ; they burst in the course of a few days, and 
pour out their contents, which concrete into dark brownish crusts. 
The crusts fall at the end of one or two weeks, and leave behind them 
purplish and indolent tubercles, which remain for some time longer, 
and subside very slowly. The inflammatory action accompanying this 
eruption often produces thickening of the integument, and frequently 
extends to the subcutaneous textures. In this way the roots of the 
hairs sometimes become affected, and fall out, leaving the skin totally 
bald. 

The eruption of sycosis is preceded by a painful sensation of heat 
and tension of the skin; this is followed by several small red spots, 
which rise in the course of a few days into conical elevations, and upon 



DISEASES OF THE HAIR. 635 

the summits of these the pale yellow pus, characteristic of sycosis, is 
formed. At their first appearance these pustular elevations are few 
and scattered ; in subsequent attacks their number is increased, until 
at last the whole of the chin and sides of the face may become thickly 
studded. 1 The eruption is variable in extent, sometimes affecting one 
side of the chin alone : at other times the whiskers and submaxillary 
region are solely attacked, while in another case the disease is confined 
to the upper lip. When the subcutaneous textures are affected, the 
integument is raised into tubercles and tumors of considerable size, 
which are more or less covered with pustules and crusts, and have a 
repulsive appearance. In this state the integument retains its tuber- 
culated, thickened, and congested appearance, sometimes for years. 
As the disease declines, the pustular elevations cease to be developed, 
the tubercles diminish in size, and the epidermis is thrown off by re- 
peated desquamations. 

Sycosis contagiosum. — Gruby, of Vienna, so well known for his 
researches into the vegetable nature of favus, and his discovery of ve- 
getable organisms in other diseases, presented a paper to the Academy 
of France in 1842, on a new cryptogamic plant, existing in the roots 
of the hairs of the beard, and around that portion which is contained 
within the hair-follicle. By the transmission of the seeds of this plant 
the disease is supposed to be rendered contagious, and he proposes for 
it the name of mentagrophyte. 

Gruby gives the following account of the disease : it is limited to 
the hairy part of the face, but is most frequently seen on the chin, 
upper lip, and cheeks. It covers all these parts with white, grayish 
and yellowish scales, which measure from two to six millimetres in 
breadth, and from three to eight in length. The scales are slightly 
raised in the middle, their borders are angular, and they are pierced 
at all points by hairs ; they are but loosely connected with the skin, 
but so closely with the hairs> that in removing a scale we at the same 
time pull out a hair. 

Examination with the microscope shows that the scales are com- 
posed of epidermal cells, but the whole of the dermal portion of the 
hair is surrounded by cryptogamic formations, which constitute a 
vegetable sheath around it, in such manner that the hair implanted in 
this vegetable sheath may be likened to the finger surrounded by a 
glove. It is worthy of remark, that these cryptogamia never rise 
above the surface of the epidermis ; they originate in the matrix of the 
hair, and in the cells of which the follicle is composed, and ascend so 
as to surround all that portion of the hair included within the derma. 
They present everywhere a prodigious number of sporules, which are 
adherent, on one side, to the internal surface of the follicle, and on 
the other to the cylinder of the hair; to the former they are closely 
connected. Each plant is composed of a stem, of several branches, 
and of sporules. 

This disease of the skin, continues Gruby, is an affection of a purely 
vegetable nature, and is deserving of occupying a place among those 

1 Portraits of Diseases of the Skin, Plate XLI., AE. 



636 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

disorders, such as favus and aphtha, which consist in the develop- 
ment of parasitic plants, and which might very properly be termed 
Nos&phyta. 

Gustav Simon adds his testimony to that of Gruby, in favor of the 
vegetable pathology of sycosis. For my own part I have failed to 
discover these vegetable fungi, and, for several reasons, entirely dis- 
believe in their existence. 

Diagnosis. — The diagnostic characters of sycosis are, the conical 
form of the pustular elevations, the bright red color of their bases, 
their deep-seated relations with the integument, the purplish and indo- 
lent tubercles which succeed them, and the site of the eruption. They 
are distinguished from acne by their situation, and by their relation 
with the hair. 

The pustular diseases, ecthyma and impetigo, have a different cha- 
racter of pustule to that of sycosis ; those of the former are large, 
prominent, and phlyzacious ; while the pustules of impetigo are small, 
little raised above the surface, clustered, and psydracious. The mode 
of termination of the pustules is equally different : in ecthyma they 
form large and thick crusts ; those of impetigo pour out an abundant 
secretion which desiccates into bright yellow crusts ; while the crusts 
of sycosis are hard, thin, and of a deep brown color. Moreover, 
ecthyma and impetigo leave behind them no tubercular thickening of 
the integument. 

Causes. — Sycosis is a disease of the male sex, but in some instances 
has been seen in the female ; it may occur at any period of the year, 
but commonly makes its attack in the spring or autumn. The most 
frequent exciting cause is the irritation resulting from the use of a 
blunt razor, in persons predisposed to such affections, on account of 
the susceptibility of the cutaneous textures. Other sources of predis- 
position are, exposure to the night air, intemperance, excess in diet, 
uncleanly habits, destitution. A common direct cause is exposure to 
heat ; hence we find sycosis to be prevalent among those who work 
near a large fire, as founders and cooks. Foville has observed the 
disease to be transmitted by contagion, from the use of a razor em- 
ployed in shaving an affected person. 

Prognosis. — Sycosis is a very troublesome and obstinate affection, 
lasting for months, and often for years. This may be inferred when 
it is recollected that shaving is frequently the primary cause of the 
disorder, and the necessary continuance of the cause cannot but pro- 
tract the chances of cure. The disease sometimes gets well spontane- 
ously during the summer, to reappear in the colder months of the 
year ; it is eventually curable. 

Treatment. — The foremost indication in the treatment of sycosis 
is the removal of the cause ; to this end, the razor must be used with 
more care, or set aside for awhile. The stimulus of excessive heat 
must be avoided, intemperate habits must be restrained, and a mode- 
rate diet enjoined. To these rules, which tend to diminish the general 
excitement of the system, may be added the use of laxatives, as the 
milder neutral salts, Seidlitz and Rochelle, preceded, according to the 



DISEASES OF THE HAIR. 637 

judgment of the practitioner, by one or several doses of calomel or 
blue pill. If the patient be full and plethoric, a general bleeding will 
be found a necessary preparation for local remedies. In the chronic 
state of the affection, it may be desirable to subject the patient to the 
influence of a course of the bichloride of mercury, and if the system 
exhibit any signs of debility, tonic remedies or steel medicines may 
be employed. I have found Donovan's solution of service in this 
affection, and have also obtained advantage from the use of Fowler's 
and De Valangin's solutions of arsenic. In the congested state of 
skin accompanying the eruption, leeches may be applied, or the part 
well scarified with the point of a lancet, both of these measures being 
followed by a fomentation of half an hour or an hour's duration, or 
by a poultice. * In the chronic state of the affection, the iodide of 
sulphur ointment (gr. x ad xx ad oj) may be tried, with a fair pros- 
pect of success, or the nitrate of mercury ointment, of its full strength 
or diluted. Other remedies that may be beneficially used in this dis- 
ease are, the benzoated ointment of oxide of zinc, the spirituous lotion 
of bichloride of mercury, a solution of sulphuret of potash, nitrate of 
silver, the juniper tar, &c. 

Whenever the hairs are loosened, they may be pulled out, as in this 
state they are apt to increase the local irritation. Plumbe regarded 
the hairs as the special cause of the obstinacy of this disease, and laid 
down rules for their avulsion ; and this method of treatment has re- 
ceived the sanction and recommendation of Hebra of Vienna. I used 
avulsion myself for some years ; but was not sufficiently impressed 
with its advantages to continue the practice ; I am induced, however, 
in deference to the opinion of so great an authority as Hebra, to give 
the plan a further and more systematic trial. Hebra applies a plaster 
to the diseased skin at night, and removes it in the morning ; and any 
hairs standing in the midst of a pustule that are not torn out by the 
plaster, he removes with the forceps. 

PAVUS. 

Syn. Crusted or honeycomb ringworm. Kerion. Porrigo lupinosa, 
Willan. Tinea lupinosa. Tinea favosa. Tinea maligna. Teigne 
faveuse, Alibert. Porrigophyta, Gruby. 

Favus (Plates XIV., XV.) is characterized by the presence of crusts, 
of a bright yellow color, scarcely rising above the level of the skin, 
covered by epidermis, exactly circular in shape when distinct, favus 
dispersus, bounded by an outline representing numerous arcs of circles 
when confluent, favus confertus, depressed or slightly cupped on the 
surface, and pierced in the centre by the aperture of a hair-follicle, 
which gives passage to one or two hairs. To these, the special cha- 
racters of favus, may be added, more or less redness surrounding each 
crust and cluster of crusts, a ragged and exfoliating state of the epi- 
dermis of the adjoining skin, a thin and glazed appearance of those 
parts of the scalp on which the disease has exhausted its violence, and 
a loss of hair in irregular patches. 

Favus is a disease of the scalp ; but, in some few instances, has been 



638 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

observed on other parts of the body. Its crusts are altogether unlike 
those of other cutaneous diseases. They are situated not upon but 
under the epidermis, and as a consequence of this peculiarity of posi- 
tion, they are smooth on the surface, and very little raised above the 
level of the skin. They are not the result of a desiccated, morbid 
secretion, poured out by a broken or ulcerated surface; 1 the disease, 
in fact, being unaccompanied by discharge of any kind, but are formed 
of a peculiar substance, a remarkable and peculiar modification of cell- 
formation and growth. 

The yellow color 2 of the crusts of favus is a striking feature of the 
disease ; the yellow is much brighter than that of pus, and this cha- 
racter enables us to discover the first traces of its appearance around 
the apertures of the affected hair-follicles. At this early period, the 
yellow substance may be seen forming a yellow ring of uniform di- 
mensions around the margin of the hair-follicle ; it is quite evident 
that it is separated from the hair by the epidermal lining of the fol- 
licle ; indeed, the aperture of the follicle is free, and generally remains 
so throughout the entire growth of the crust, and no pressure exerted 
upon the skin can force through it the morbid formation, otherwise 
than by rupture. 

The growth of the crust is eccentric, fresh matter being deposited 
in successive rings around that which was first formed, the breadth 
of the ring undergoing a gradual increase. This mode of growth is 
conspicuous on the surface of some of the crusts wherein the first 
formed rings have become altered in color by desiccation, and their 
outlines may be distinguished as a series of reddish-brown, and con- 
centrically-arranged lines. The alteration of color here referred to 
being the effect of desiccation, the whole central part of the crust 
assumes more or less of a reddish-brown tint. 

This mode of growth of the crusts also gives rise to another of its 
characters, namely, the depressed centre, which has gained for the 
disease the appellation of favus (honeycomb). But it is ludicrous to 
compare the slightly depressed and precisely circular crusts of favus 
with the deep hexagonal cells of the honeycomb ; and we cannot but 
regret that, the scientific denomination of the disease is so little appro- 
priate. The first formed rings of favous matter naturally shrink as 
the latter loses its fluid by desiccation ; but the last formed ring, re- 
taining its moisture, is brighter colored and more prominent than the 
rest, and is the chief cause of the central depression of the crust. Oc- 
casionally, the central part of the crust, namely, that which immediately 
surrounds the hair-follicle, forms a slight prominence, and destroys 
the exact concavity of its surface. 

At its outer margin the crust gradually sinks to the level of the 

1 Bateman is consequently wrong in speaking of the crusts as being formed "by the 
concretion of the fluid which exudes when they (the pustules) break.'' 

2 From leaning with too much reliance on the older writers, Bateman has fallen into 
the mistake of calling the crusts "yellowish white"' and "white." The source of his error 
is the following quotation from the Arabian author, Haly-Abbas : " Quinta est lupinosa, 
sicca, et colore alba." 



DISEASES OP THE HAIR. 639 

surrounding skin, and the epidermis passes from one to the other with- 
out change. 

Such is a description of the crust when uninjured and entire, but in 
many instances its surface, being dry and brittle, cracks in a circle 
around the hair, in consequence of the contraction of the favous 
matter during desiccation, and the component substance of the crust 
is more or less exposed to view. Occasionally, the central follicular 
piece of the crust becomes loosened from the rest, and either adheres 
to the hair or is drawn upwards on its shaft, and has the appearance 
of being strung like a bead upon its thread. The exposed substance 
of the crust is lighter-colored (cream-colored) than its surface, and more 
or less broken into small masses, according to its degree of dryness. 
It is this latter character that Bateman alludes to when he says, that 
the " central indentation or depression sometimes contains a white, 
scaly powder." It will be seen at once that Bateman is wrong in this 
expression, for the surface of the crust is gone before the disinte- 
grated appearance alluded to comes into view, and then even it is not 
a "scaly powder." This remark of Bateman's is evidently the "a 
qua quasi cortices et squamae fluunt albae" of Haly- Abbas. 

In its early development the crust of favus is exactly circular, and 
it maintains this form with remarkable accuracy even when neighbor- 
ing haii*s are implicated in its progress, so that, as it sometimes hap- 
pens, the crust is transfixed by several hairs, one or two being cen- 
tral, and representing the starting-point of the morbid action, the 
others being more or less peripheral. Occasionally, two or three 
crusts approximate in their growth, and become blended by their mar- 
gins ; and in the aggregated or confluent form of the disease a number 
are thus united together. In the aggregated mass, however, the cir- 
cular form and depressed centre of the originally separate crusts are 
still perceptible. 

The size of the crusts is something less than a quarter of an inch 
in diameter, namely, between two and three lines. Bateman speaks 
of them as acquiring the size of a sixpence, which is incorrect. 

Passing now from the outward characteristics of the disease to the 
relation subsisting between the morbid formation and the skin, we find 
that if, with a little care, we break through the epidermis around the 
margin of the crust, we are enabled to raise up and remove the entire 
crust without drawing blood or injuring the skin. And if we perform 
this manipulation after the removal of an oil-silk covering or poultice, 
which has been allowed to remain on the head for a few hours, we may 
succeed in peeling off the whole of the crusts without pain to the 
patient, and with the utmost facility, the crusts being unbroken, and 
retaining their exact form. Moreover, in the course of withdrawal, 
the crusts will be unthreaded from the hairs, leaving the latter behind 
standing firmly in their follicles. 

In this manner we are enabled to demonstrate that the under-sur- 
face of the crust is smooth and convex, and of a honey-yellow color, 
and that there is frequently a prominent papilla, corresponding with 
the aperture of the follicle of the hair, which is prolonged downwards 
from the centre of the convexity. The crust is thick throughout its 



640 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

entire extent, but thicker in the middle than at the periphery, and, at 
its thickest part, measures from one-half to one-third of a line. 

On the surface of the derma there exists a depression corresponding 
with the dome-like convexity of the under part of the crust. This 
surface is smooth, shining, and red; and is evidently constituted by the 
basement membrane, which is transparent, but somewhat thickened. 
In the centre of the depression is the aperture of the hair-tube unaf- 
fected by the morbid action; and if the hair be withdrawn, it is evident 
that it has no direct participation in the disease. The under surface 
of the compound crust displays the numerous domes of the originally 
separate crusts, and the impression on the derma is that of a number 
of cups divided from each other by prominent partitions. 

The structure of the derma has obviously suffered absorption, from 
the gradual and prolonged pressure which has been kept up on its sur- 
face. The derma has become thinned, all trace of papillre is lost, and 
the hair-follicles are shortened. A further continuance of this pres- 
sure, occasioned by a further addition of favous matter to the under 
part of the crust, would entirely obliterate the hair-follicles, and then 
the formation of hair would cease. This is the explanation of the loss 
of hair which takes place in favous disease. 

After the removal of the crusts, it is curious to observe how quickly 
the compressed derma becomes lifted up. In the course of a few hours 
the depressions are almost effaced, and a film of epidermis is formed 
upon their surface. But if the pressure have been great, or of long 
duration, the normal level is never completely regained, and the skin 
frequently retains its thinned and atrophied character for the rest of 
life. The papillfe of the derma having been destroyed, the restored 
surface is unnaturally smooth, and covered by a transparent and flaky 
epidermis, which is repeatedly thrown off by desquamation. The in- 
jured hair-follicles admit of no regeneration, and the diseased spots 
therefore remain permanently bald. 

The color of these altered patches of skin is that of a portion of in- 
tegument which has long suffered under chronic inflammatory action ; 
in relaxed constitutions the veins are dilated, and the torpid circula- 
tion gives rise to a blueness and lividity of hue. In more healthy 
states of the system, the tint of color is paler than that of the sur- 
rounding surface, in consequence of the diminished amount of the 
capillary rete of the skin. 

According to the preceding observations, the precise seat of the 
morbid formation of the favus is the surface of the derma. The morbid 
substance lies in contact with the basement membrane of the derma on 
the one hand, and with the epidermis on the other. From the derma, 
as I have already shown, the favous substance is easily separable; but, 
with the epidermis, it is closely identified. Its relation to the epi- 
dermal lining of the follicle of the hair is similar to that of its con- 
nection with the epidermis. 

Pathology. — When we proceed to the anatomical analysis of a 
crust of favus, we find it to present some diversity of texture in dif- 
ferent parts of its thickness. The upper surface, for example, being 
combined with the epidermis, evinces the laminated disposition of that 



DISEASES OF THE HAIR. 641 

membrane, and is brittle from its dryness. The deep surface is of a 
darker yellow than the rest, of a honey-yellow color, and conspicuous 
for its density and toughness; tearing with difficulty when dissevered 
by needles for microscopical examination. The middle portion, 
which constitutes the greater bulk of tbe crust, is cream-colored, be- 
coming, when moistened, as yellow as the deep surface, and broken 
up into small irregular masses, like mud dried in the sun. 

Under the microscope, these three divisions of the crust, namely, 
its deep, middle, and superficial portions, present differences of struc- 
ture which I will now describe. 

The deep portion is composed of globular corpuscles, measuring 
Woo* Woo °f an mcn m diameter, closely collected together and 
forming the outward boundary of the crust. Each corpuscle is con- 
structed of a cell-membrane inclosing numerous very minute second- 
ary cells (To5oo to 5o ! oo)j anc ^ tne l atter are formed of several minute 
transparent granules (j^ooo to T2ooo)- ^ n tne centre of each of the 
secondary cells is a dark point, which might be regarded as a nucleus, 
but which, in reality, is merely the shade caused by .the approxima- 
tion of the elementary granules of which it is made up. 

The middle portion of the crust is composed of corpuscles much 
larger than the preceding, namely, between 25 ^ and T5 ] p 5 of an inch 
in diameter, and consisting of a cell-membrane, containing from four 
to seven or eight nucleated granules; of nucleated granules (^Lj), 
separate and in groups; and of other nucleated granules connected 
together in a linear series, and assuming a branched and plant-like 
form. 

The superficial portion is remarkable only for the large size of the 
nucleated granules, and for the more highly developed condition of 
the plant-like growth. In it there are no corpuscular cells. 

In its essential nature, I believe the peculiar matter of favus to be 
a modification of the elements of the epidermis. The grounds upon 
which I found this view I will now explain^ 

The epidermis is originally a plastic fluid, which goes through the 
successive forms of elementary or primitive granules, aggregated 
granules, nucleated granules, and cells, before it attains its ultimate 
condition of flattened scales. 1 

Now, the favous matter is necessarily in a fluid state when first 
effused through the capillary vessels on to the surface of the derma, 
and in its freshly elaborated condition consists of granules, possessing 
a simple, aggregated, and nucleated shape, and cells. I have ascer- 
tained the presence of these elementary forms. The primitive gra- 
nules measure from 3^uotj*°T20uu °f an * nc h * n diameter; the nu- 
cleated granules measure 45^0 5 an( ^ tne cc ^ s between 5li T 00 and 3^^. 

The primitive granule is the first organic shape of the plastic fluid 
effused by the blood, and the process by which that shape is assumed 
is a kind of vital coagulation or vital crystallization. The granule 
is endowed with an independent life, and is capable of acting both 

1 Page 39. 
41 



642 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

alone and in combination with similar granules. It separates from 
the plastic material by which it is surrounded the elements of growth, 
and attracting towards itself other granules, forms an aggregated 
granule ; the aggregated granules performing similar actions, con- 
stitute nucleated granules ; and several of the latter combining in a 
like manner and forming around themselves a peripheral boundary, 
constitute a cell. The growth of the cell is the result of the vital 
agency of the whole of the contained primitive granules. These gra- 
nules draw nutritive material from the blood, which nutritive material 
serves the double purpose of contributing to their own growth and 
giving origin to new granules, so that the same changes occur within 
each cell as had taken place in the plastic fluid poured out on the 
surface of the derma. 

Reasoning from analogy, the mode of development and growth of 
a cell must be the same in whatever part of the body it is produced, 
and whatever special purpose it may have to perform; and microsco- 
pical investigation establishes the existence of an identity of structure 
among them. The blood-cell, the mucus-cell, the pus-cell, the pig- 
ment-cell, the epithelial or epidermal-cell, for example, resemble each 
other closely in construction, and in some instances appear to be con- 
vertible the one into the other. The cells or corpuscles of favus 
possess a striking resemblance to pus-cells, and, excepting in their 
form, are closely allied to young epidermal-cells; so that it would 
require no stretch of imagination to suppose the epidermal-cell, altered 
in its actions by disease, capable of assuming the character of the pus- 
cell ; or the latter, from a similar cause, passing into the likeness of a 
favus-cell. 

In the early development of favus it is no uncommon thing to see 
around the aperture of a hair-follicle a circle of pus in place of favous 
matter. There is no difficulty in distinguishing between the two, for 
pus is much lighter colored than the matter of favus, and when the 
epidermis is punctured, issues from its cavity in the form of a drop. 
In a very short time, however, this little collection of pus loses its 
characteristic color; it becomes, as it were, dried up, is no longer 
recognizable as pus, and merges into the yellow crust of favus. Now, 
in this fact, we have evidence that the same tissue may produce, one 
while, epidermal-cells; another while, pus-cells; and thirdly, favus- 
cells. Can we close our minds against the signification of so remark- 
able a phenomenon? 

The fact of pus being so easily distinguishable from the matter of 
favus may, at first sight, appear to offer a contradiction to the analogy 
which I wish to establish, but the difference between the two is more 
apparent than real. Pus is fluid, from the presence of a large quantity 
of water, and this dilution with water necessarily alters the color and 
modifies the development of the corpuscles. Favous matter, at its 
softest, appears in the state of paste. 

A drop of pus from the situation referred to was composed of glo- 
bular corpuscles 3 ^ 0IJ of an inch in diameter floating in liquor puris. 
The corpuscles presented the ordinary granular appearance of pus; 
but when water was added, they swelled to the size of 2^^ of an 



DISEASES OF THE HAIR. 643 

inch ; and, in place of the minutely granular structure "which they 
previously had, displayed in their interior from four to seven or eight 
large granules or nuclei. I will not stop to inquire by what means 
this change was effected. Imbibition of water was evidently one of the 
phenomena, but what the process might have been by which the 
minute granules, or rather cells, which were previously seen, were dis- 
persed, is a matter of no importance to the present investigation. 

Now the corpuscles which form the deep layer of the crust of favus 
are composed of seven or eight granules, which represent the nuclei 
of the cell. The size of the granules varies between T o^tjo an ^ s^otj 
of an inch, while that of the entire cell is 3^5. So that these cells 
correspond very accurately with the multi-nucleated pus- cells, the only 
difference between them being the distension of the cell-membrane of 
the pus-cells with water. 

It is interesting to observe the development of these favus-cells as 
they become displaced, by successive formations, from the surface of 
the basement membrane, and proceed onwards towards the centre of 
the crust. The nuclear granules gradually enlarge until they attain 
the 430^ of an inch, a size nearly approaching the bulk of the original 
cell ; and the cell in which they are contained measures between %-^-q-q 
and T g(j(j of an inch. At this period the function of the cell appa- 
rently ceases, for its membrane becomes broken and lost; many of the 
nuclei are dispersed, but many also remain adherent to each other, 
and may be observed in linear groups of two, three, and even four or 
five, already assuming a plant-like character. 

In recapitulating the changes referred to in the preceding para- 
graphs, it would appear that the vital force inherent in a plastic fluid 
is employed in the development of molecules of extreme minuteness, 
primitive granules; that these granules combine and co-operate for 
the formation of cells; and that the aim of the cells is the production 
of nuclei or secondary cells. We will now examine these secondary 
cells, and follow the subsequent changes which take place through 
their means. 

It is quite evident that these secondary cells are themselves 
nucleated. In some instances a single nucleus only is perceptible; 
in others, two; and in others, again, three. When two nuclei are 
apparent, the secondary cell assumes an oval' or oblong form; and 
when there are three it has a three-cornered shape. As soon as the 
cell has attained an elongated form a slight contraction is apparent 
around its middle, and a septum is thrown up which divides it into 
two cells; in a short space of time each of these cells develops two 
nuclei, which separate by degrees, and are finally parted by a septum, 
as in the previous case; a third repetition of similar actions might 
convert the four into eight cells, and in this way an elongated stem 
is produced, which has all the appearance of a vegetable formation. 
When, in place of two, three nuclei are developed at the same time, 
the Stem has a dichotomous character, and seems to have resulted 
from the growth of two branches from one stem; and the occurrence 
of a trinucleated cell in the course of growth of a stem is the usual 
mode of origin of a branch. 



644 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

When the process of growth which is here described is accom- 
panied by an active nutritive force on the part of the cells, the 
cellated stems maintain the original diameter of the cells from which 
they spring. But when the nutritive force is less active, or the growth 
is more energetic, then the stems dwindle in size in a corresponding 
ratio. This, I apprehend, is the signification of the considerable range 
of variety in breadth which these stems exhibit ; the thicker ones 
measuring gI ' 55 to ^j^ of an inch, and the smaller T ji 5?5 . It cer- 
tainly has no reference to trunks or branches, as the idea of a vegeta- 
ble growth might suggest. 

The thickest and largest cellated stems are found in the upper 
portion of the favous crust, the most slender in its deeper portion ; 
while in the middle portion, stems of every intermediate size are 
found mingled with secondary cells in vast numbers. These, namely, 
the stems and secondary cells, together with the primary cells and 
primitive granules, being the real constituents of the crust. 

The stems offer some slight differences in relation to the contents 
of their cells; in some, and especially in the large ones, the contents 
are transparent and the nuclei manifest, while in the smaller stems, 
they are finely granular. 

The resemblance which the cellated stems of favus bear to some 
of the inferior vegetable organisms, and especially to the mucedines, 
has caused them to be considered as plants. They have been described 
as originating in the cortex of the crust and 
growing inwards towards the centre, as giving 
off numberless branches, and producing seeds 
or sporules in vast abundance; the so-called 
sporules being the secondary cells of the pre- 
vious description. With all these plant-like 
characters hypothesis speedily reached the 
conclusion that the sporules must be the 
means of disseminating the disease; in other 
words, were the elements of contagion. Now, 

A portion of the yellow matter T , . -, , . . p .. , . . 

from the crust of honeycomb I think, that any one who has followed with 
ringworm, showing its plant like attention the argument contained in the pre- 
b ructure. ceding narration will agree with me, that 

mere resemblance to a vegetable formation 
is not sufficient to constitute a plant. The statement of the origin of 
the vegetable formations by roots implanted in the cortex of the crust 
is unfounded, the secondary cells bear no analogy to sporules or seeds, 
and it is somewhat unreasonable to assign to an organism so simple 
as a cell the production of seeds and reproduction thereby, when 
each cell is endowed with a separate life and separate power of repro- 
duction. 

Again, it has heretofore been assumed that the favous matter was 
contained in the hair-follicles, and consequently in communication 
with the exterior ; a presumption which rendered the idea of a plant- 
like formation the more probable. But if, as I have shown, the favous 
matter is sub-epidermal, and has no communication with the exterior, 
it will be necessary to admit the production of a vegetable organism 




DISEASES OF THE HAIR. 645 

within the animal tissues, before such a phenomenon can be received 
as possible. The mucedinous formations which have been described 
hitherto as having been discovered in the animal body, have always 
been found on the surface of membranes, and not in the substance of 
tissues, as is the case with favus. 

In chemical composition, the crusts of favus, according to the 
analysis of Thenard and Chevillot, consist in every hundred parts, of 

Albumen, ....... 70 parts. 

Gelatine, ..... . . 17 " 

Phosphate of lime, ...... 5 " 

Water, 3 " 

Loss, ........ 5 " 

State of the hair in favus. — In a preceding paragraph I have stated 
that the hair remains standing in its follicle when a recent crust is re- 
moved, and, I may add, that if the hair be drawn out, it will be found 
unaltered in appearance. It is only when the favous matter has in- 
creased to the extent of obliterating the follicle that the hair falls. 
If the obliteration of the follicle be complete, no new hair is formed, 
but if it be only partially destroyed, then a hair may be produced of 
smaller diameter than the original hair, or somewhat lighter in color. 
It is unreasonable to expect that so serious a disturbance of cell-for- 
mation, as that Avhich occurs in favus, can exist in the scalp, without 
interfering in some degree with the structure of the hair, itself a pro- 
duct of cell-formation. Such an interference does take place, and the 
nature of the morbid alteration I shall now explain. 

When a hair from the midst of a crust of favus is placed under the 
microscope, it is seen to be traversed in the direction of its length by a 
number of cylindrical tubes measuring in diameter T oijoo °f an i ncn - 
A close examination shows that these tubes are divided by transverse 
septa into small spaces a very little longer than their breadth, and are 
filled with air. Now, an observer imbued with the vegetable theory of 
favus would be likely to conclude that these were the stems of a muce- 
dinous plant, and so indeed they have been considered. They have 
also been described as branching dichotomously, an assumption alto- 
gether unfounded in fact. 

To understand the true nature of these tubes, it is necessary to go 
back to the structure of the hair. The middle or fibrous layer of the 
hair is composed of oval-shaped cells, closely packed together, and ar- 
ranged in a linear order. These cells are identical in structure with 
the cells of the deep stratum of the epidermis, that is to say, they 
are composed of granules congregated around a central granule which 
constitutes the nucleus of the cell. When examined with the micro- 
scope, it is not easy in all cases to discover the cells, but their compo- 
nent granules are always obvious, and from the plan of disposition of 
the cells and their oblong shape, the granules have a linear arrange- 
ment, and assume the appearance of fibres. The hair-fibres offer some 
variety of aspect according to the focus in which they are viewed. 
For example, with a superficial focus, the peripheral granules are alone 
seen, and the hair appears to be entirely composed of granules ar- 
ranged in single rows. With a deeper focus, the rows of granules ap- 



646 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

pear to be associated in pairs, each pair having between them an un- 
connected row of dark and apparently nuclear granules. In this view, 
the fibres resemble a chain composed of open links. While, with a 
still deeper focus, the centre of the cell, with its nucleus and granular 
periphery, is brought into view. 

Now the hair-fibres here described, are composed of cells arranged 
in a linear series, and the cells are filled with a homogeneous albumi- 
nous substance, having a certain consistency, and possessing the cha- 
racters of a solid. Under the influence of disease, the contents of the 
cells are so far modified as to be deposited in a fluid form, and the sub- 
sequent evaporation of the fluid, during the growth of the hair, leaves 
the fibres hollow and empty, and to all appearance tubular. This is 
the explanation of the hollow tubuli which are found in the structure 
of the hairs in favous disease; generally they are distributed in small 
numbers throughout the thickness of the hair, and produce no influ- 
ence on its shaft ; when more numerous they occasion the lightness of 
color of the hairs before mentioned, and their somewhat shrivelled ap- 
pearance. But it is evident that they offer no analogy with the plant- 
like formation of the crusts of favus. When the hairs present the 
tubular structure to any great extent, they become brittle, and are 
easily broken. 

Symptoms of favus. — The early part of the course of this disease is 
attended with a moderate amount of itching. At a later period, when 
the crusts have enlarged, and are producing pressure on the inflamed 
skin, the scalp is tender and painful, particularly in resting the head 
on the pillow at night. When the disease is neglected, the pressure 
of the crusts, together with scratching with the nails, may give rise to 
ulceration, and, according to the French writers, these ulcerations 
have been seen extending even to the bones of the cranium. The dried 
crusts give out a peculiar odor, like that of mice ; and when the skin 
falls into a state of ulceration, the discharge is said to be most offen- 
sive, resembling, according to Alibert, the urine of cats ; and pediculi 
are apt to be engendered in great numbers. 

When the state of irritation and inflammation of the scalp are great, 
the occipital and cervical lymphatic glands are apt to become painful 
and enlarged. This is a common occurrence in inflammation of the 
scalp, and one that I have had frequent occasion to observe, even in 
cases of inflammation artificially excited. I make this remark, be- 
cause some dermatologists would lead us to infer, that enlargement of 
the lymphatic glands of the neck is pathognomonic of favus. In the 
most severe and neglected cases of favus, the inflammation of the 
lymphatic glands has gone on to suppuration and ulceration. 

Causes. — Favus is a disease of deranged nutrition, and generally 
occurs in childhood, at a period of life when the nutritive functions 
are most active, and when, as a consequence, they are most susceptible 
of disturbance. At this age, any circumstance which may tend to 
reduce the powers of the system may become a predisposing cause of 
favous disease. Favus is generally met with among the children of 
the poor, and in those institutions for the children of a better class, 



DISEASES OF THE HAIK. 647 

that are so mismanaged in respect of diet, clothing, ventilation, and 
cleanliness, as to engender a disposition to disease. 

The more frequent occurrence of favus in France than in England 
is, I believe, attributable to the greater poverty and wretchedness of 
the lower classes in the former country, added to a practice which is 
happily almost unknown in England, namely, the putting out of the 
children to nurse. The remark has been handed down from author to* 
author, that children afflicted with favus remain stunted in their 
growth, are slow in displaying the changes which take place at puber- 
ty, and are wanting in their intellect. "I have seen," says Biett, 
"individuals affected with this disease evince no signs of puberty at 
the age of twenty, and even more." 

In my opinion, these phenomena of retarded development are not 
the effect, but a part of the general deficiency of power, in other 
words, of the defective nutrition, which is the real cause of the 
disease. 

Is favus contagious? The transmitted records of the older writers 
and modern authors both agree in according to favus a high degree 
of contagious power. The supporters of the vegetable theory of the 
disease are still more ardent in this belief; for, with a distinct muce- 
dinous growth and a host of sporules, it would be hard, indeed, if the 
disease were not susceptible of propagation. This theory will also win 
admirers and disciples from the simple and truth-like explanation 
which it seems to offer of the manner of transmission. The seeds are 
conveyed directly to the soil in which they take root and grow; they 
are carried by combs, or brushes, or hands, or they are wafted by the 
winds. Gruby made the contagious property of favus the subject of 
experiments; he inoculated with the substance of the favous crust 
mammiferous animals, birds, reptiles, insects, and himself, but without 
any success. He also inoculated vegetables with the same matter, and 
after seventy -six trials, he found a mycodermis similar to that of favus 
produced on a cryptogamic plant. 

I am exceedingly doubtful of all that has been recorded with regard 
to the contagiousness of favus. The experiments of Dr. Gruby prove 
nothing in its favor, for the instance to which he refers is merely one 
of the formation of a mucedinous plant, in other words, of a crop of 
mould upon a wounded cryptogamic plant. The identity of this 
mucedo with the " porrigophyte,' r or plant of favus, being far from 
being established. 

The seat of development of favus affords a common-sense negative 
to the notion of propagation by seeds or sporules; and if it be true, 
as I have endeavored to prove, that the plant-like production has 
nothing in common with plants but its form, a form which is as con- 
stant in animal structures as in plants, the vegetable theory of the 
disease must necessarily fall to the ground. 

I will now adduce a different line of argument. In the course of 
my long connection with the St. Pancras Infirmary, I have seen not 
more than six eases of favus; in no one instance Avas there reason to 
suspect the disease to have originated in contagion, and certainly 
there was no example of its transmission to others. In a well-marked 



648 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

illustration of this disorder, the features of which I have preserved by 
delineation, 1 the patient, a boy, ten years of age, had suffered from 
favus for seven years. He was brought up with a brother and sister; 
and on the last occasion of the outbreak of the disorder, was one of a 
t school of one hundred and fifty-eight boys. He remained in the school 
until the disease was fairly developed over the greater part of his head, 
and was then transferred to the Infirmary, where he was accustomed 
to play with several invalid companions. Now, during the whole 
course of his association with other children, although he partook of 
their games without restraint, although he washed in the same water, 
and used the same towel and comb, the disease was never communi- 
cated to others ; it never extended beyond himself. 

Bateman, who was an ultra-contagionist, and gave the specific title 
of " contagiosum" to a very harmless form of disease of the sebiparous 
glands, namely, the "small sebaceous tumors" of my classification, 
opens his history of diseases of the scalp by the observation that " the 
porrigo is a contagious disease." This sweeping condemnation is 
immediately followed by an exception in favor of porrigo larvalis ; to 
which might have been added, without any hesitation, porrigo favosa, 
and porrigo decalvans ; so that, on the threshold of inquiry into the 
contagiousness of porrigo, one-half the species of that writer might 
have been declared at once to be free from imputation. The remaining 
three species, or, as I have shown, two, for porrigo furfurans and por- 
rigo scutulata are stages of the same disease, are, therefore, the only 
affections about which any doubt can exist in the minds of persons con- 
versant with cutaneous diseases. 

The impression made on my mind by the perusal of the account of 
favus (porrigo lupinosa) which is given by Bateman, is, that he cannot 
have been familiar with the disease, and that his description is not 
drawn from nature, but composed from the writings of the older 
medical authors, who, in this instance, had certainly observed the 
disorder very imperfectly. The term " porrigo," he tells us, was 
adopted by Willan, " nearly in the same sense in which it was used 
by Celsus, who included the moist and ulcerating, as well as the dry 
and furfuraceous, eruptions of the scalp under this denomination." 
He further observes, that " numerous writers, ancient and modern, 
have designated the varieties of the disease (porrigo) by distinct 
names, such as crusta lactea, alopecia, pityriasis, favi, achores, scabies 
capitis, &c. ; but the most intelligent observers have pointed out the 
identity of the nature and causes of these eruptions ;" from which 
it may be inferred that the " ancient and modern writers" were greatly 
superior, in point of discrimination, to the " most intelligent observ- 
ers;" for, of a surety, nothing can be more widely dissimilar or non- 
identical than the diseases represented by the six designations 
mentioned above. In the absence, therefore, of facts, and something 
in the shape of proof to the contrary, I must be permitted to doubt, 
not only the contagion of favus, but also the qualification of Bateman 
to speak to the subject. It is further worthy of remark, that in the 

1 Portraits of Diseases of the Skin, Plates XLII., XLIII., B, C. 



DISEASES OF THE HAIR. 649 

plates of cutaneous diseases published by Willan and Bateman, there 
is not one which represents favus. 

Plumbe commences his treatise on porrigo by adverting to " its 
known infectious nature." He alludes to favus only as the crusted 
stage of common ringworm, and that so lightly that it is evident that 
he cannot have observed the disease with attention. On its contagious 
property he is obviously no authority. 

It appears that favus, which is rare in this country, is common in 
France. "Next to eczema and impetigo," says Rayer, "favus is the 
most common of the chronic inflammations of the hairy scalp." Again, 
he observes, " favus is a contagious disease, and is readily communi- 
cated among children who make use of the same comb and brush, 
especially if any slight excoriation happen to exist on the scalp." He, 
furthermore adduces the evidence of Willan, in proof of the conta- 
gious qualities of the disease, and concludes with ' the erroneous 
observation that " the complaint is very common in England." 

Biett records that favus is " evidently contagious, but in some cases 
the attempt to produce infection has entirely failed." Gibert ob- 
serves, that the " contagiousness of favus is acknowledged by almost 
all pathologists ;" he then unfortunately adduces the evidence of 
Bateman, and, after making mention of some instances which prove 
too much, he finishes up with the following remark : " The conta- 
giousness of favus is then an established fact." In fairness to him I 
will now quote his illustrations, however little weight they may have 
with myself. " In the wards of Biett, two or three instances have been 
seen of the propagation of this disease by the act of kissing, the dis- 
order making its appearance in these cases around the mouth and on 
the chin. In a patient who wore a wig Avhich had belonged to a per- 
son affected with favus, the latter disease broke out on the arms and 
legs. This curious circumstance was explained when it was ascer- 
tained that the wig always came off during the man's sleep, and was 
found in the bed in contact either with his arms or legs. Some years 
since M. Guersent had occasion to see, in a school, twelve children 
who were successively attacked with favus within the space of a few 
weeks or months, in consequence of the admission of a child affected 
with that disorder." 

There is too much of a blind and unthinking deference to the state- 
ments of predecessors in all these examples. In some instances, I 
make no doubt, the case was not favus at all; and in others, commu- 
nication by contact has been admitted with too little consideration. 
The breaking out of a disease in a number of children breathing the 
same air, partaking of the same food, and living under the same 
hygienic influence, is a circumstance of daily occurrence, and one 
tut, illy distinct from contagion ; and if, as I have shown, a free asso- 
ciation continued for years between an affected individual and others 
has failed in transmitting the disease, the power of transmission may 
be reasonably doubted. It is encouraging to find an original thinker 
like Alibert refusing his assent to the current belief in the contagious- 
ness of favus. 

Finally, whether we regard favus in its origin, in its development, 



650 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

or in its essential nature, or whether we look at its phenomena in a 
social point of view, its extreme rarity, and the indisposition to trans- 
mission which it evinces when closely observed ; in each and every of 
these features of the disease we shall find reasonable grounds for 
doubting its propagation by contagion. My own careful investiga- 
tions of the subject have forced on my mind the conclusion that favus 
is not contagious. 

Treatment. — The indications for the treatment of this disease are 
two in number, the first being to restore the defective powers of the 
constitution ; the second, to restore the local power of the skin. 

The fulfilment of the first indication calls for improved hygienic 
conditions, improved diet, tonic alterative medicines ; that of the 
second requires the aid of local remedies belonging to the class of 
abluents, stimulants. The four great hygienic principles, namely, air, 
exercise, clothing, and ablution, deserve the first, and especial atten- 
tion in this disease. Favus is usually engendered in the confined and 
malarious homes of squalid misery, and the most opposite conditions 
to these should be selected in our treatment ; the patients should be 
sent to a spot located on a dry soil, breathed upon on all sides by a 
bracing, healthy air, uncontaminated by the steams and impurities 
which rise from the congregated abodes of human beings. The apart- 
ment in which he sleeps should be thoroughly ventilated ; it should 
be large and lofty ; he should lie in a separate bed, and the number 
of persons sleeping in the same room should be as few as possible. 

The subjects of this disease are for the most part children, therefore 
exercise is a paramount necessity. The physical, and not least 
important, education of children, consists in, eating, drinking, sleep- 
ing, moving, building up a healthy structure, and furnishing that 
structure with a sound constitution and sound mind. If the physical 
phenomena of life are well and truly performed, Nature will have no 
time for pathological actions. 

The clothing of children suffering under this disease should be 
carefully adapted to their own feelings, and to the temperature of the 
season. It should be kept strictly clean, and frequently changed. 
Ablution is another important consideration. The sponge bath 
should be used daily ; local ablution is of little value in comparison 
with general sponging. 

Attention to the diet of persons suffering under favus is of the 
utmost importance. As a general rule it should be animal and 
nutritious, and only moderately fluid. Much vegetable food should 
be avoided, and all matters which obviously disagree with the 
stomach. The best directed medical treatment can do but little when 
the diet is based on a meagre standard. 

The medicine which, above all others, is best adapted for favus is 
iron. The formula is not very material ; I have used the citrate, 
acetate, and sesquichloride ; the latter I prefer. The dose which I 
prescribe for a child of ten years is ten drops of the tinctura ferri 
sesquichloridi on sugar, twice or three times in the day. The iodide 
of iron is also a useful remedy. When the powers of the system 
are much enfeebled, the citrate of iron and quinine is an excellent 



DISEASES OF THE HAIR. 651 

remedy. Where iron produces heat and dryness of the mucous mem- 
branes with feverishness, I use the nitro-muriatic acid, either as a 
sherbet, or combined with tincture of orange-peel or gentian ; and in 
chronic and rebellious cases, the ferro-arsenical mixture. 

If there be any tendency to strumous enlargement of the lymphatic 
or mesenteric glands, I recommend the oleum jecoris aselli ; and if 
any tendency to slenderness and flexure of bones, lime-water, or 
phosphate of lime. It is hardly necessary to observe that the ordinary 
functions of the body should be watched and regulated by the usual 
means ; but, as a general rule, aperients and purgatives are injurious, 
and to be avoided. 

To restore the local powers of the skin, it is necessary to have 
recourse to local remedies. In the first place, the crusts must be 
removed, a manoeuvre which is easily accomplished, by impregnating 
the scalp thoroughly with oil at bedtime, and washing it in the 
morning with water and soap. A few repetitions of this process will 
suffice to clear away the crusts effectually. The same end may be 
attained by means of a linen compress moistened with a weak solution 
of subcarbonate of potass, and an oiled-silk cap worn for two or three 
nights ; by a poultice ; or, better still, by means of a piece of Alison's 
prepared lambskin. I am not favorable to the practice of frequent 
ablution with soap. When the crusts are once removed, a saponaceous 
ablution is not again required until they re-collect ; nor do I 
approve of shaving the head ; the only ground for this practice being 
cleanliness. 

I now come to the means to be adopted to alter and suspend the 
abnormal actions taking place in the skin, while nature restores by 
degrees its wonted functions. The agents for affecting this purpose 
are local stimulants, and the best of these the ceratum tiglii, contain- 
ing from ten to thirty drops of the oil to the ounce ; the unguentum 
hydrargyri nitratis, diluted one-half; the unguentum hydrargyri 
nitrico-oxydi, diluted in similar proportion ; the compound sulphur 
ointment ; or the sulphuret of potash lotion (5j ad Oj), with ceratum 
camphorae, half a drachm to the ounce. In chronic cases, where 
the above remedies may have failed, they might be used in a more 
concentrated form. I am less favorable to strong applications now 
than when I began the treatment of cutaneous diseases ; but in 
some instances I have derived benefit from tincture of iodine, and a 
spirituous solution of bichloride of mercury. Devergie recommends 
touching the crusts with a solution of nitrate of mercury in nitric 
acid. Creasote and tar I rarely use, on account of their powerful 
odor; and in this disease they possess no especial virtue. The iodide 
of sulphur I have found to exhibit no superiority over simpler 
remedies. 

An unfounded notion has long prevailed among writers on cutaneous 
disorders, that the hairs in this disease act as a source of irritation. 
Some have considered the roots of the hairs to be the seat of origin 
of the morbid action, and the loosening of the hairs is an idea that 
has been commonly entertained. Plumbe was an advocate for the 
removal of all loosened hairs by means of the forceps. Rayer 



652 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

observes, " In old standing cases of favus of the scalp, every method 
of treatment into -which the avulsion or removal of the hair does not 
enter as an element is incomplete, and unworthy of being entitled 
curative." "The oldest system of this kind consisted in tearing out 
the hair violently by means of some adhesive plaster, which was 
applied to or spread over the scalp. To prepare this plaster, it was 
customary to mix four ounces of rye-flour in a pint of cold white- 
wine vinegar ; the mixture was set upon the fire and stirred continually, 
whilst half an ounce of the deuto-carbonate of copper (verdigris), in 
powder, was added ; it was boiled for an hour, after which four ounces 
of black pitch, the same quantity of resin, and six ounces of Burgundy 
pitch were added. When all these ingredients were melted and incor- 
porated, six ounces of antimonial ethiops (an alloy of mercury and 
antimony obtained by long trituration) in fine powder, were thrown 
into the mixture, which was stirred till it had acquired what was held 
to be a proper consistency. The plaster thus prepared was spread 
upon a stoutish black cloth, which was slit in different directions before 
being applied, to prevent it from forming a crease, and to admit of its 
being subsequently removed in stripes. 

" The plaster was applied to the head, after having got rid of the 
incrustations, by softening them with cataplasms, and having clipped 
off the hair as close to the skin as it could be done with scissors. 
After the lapse of three or four days, the plaster was removed 
rapidly the contrary way of the hair, and a second was put on, which 
was likewise removed in the same manner, three or four days after 
its application. The plaster was subsequently renewed, every second 
day, taking care to have the head shaved whenever this measure 
appeared necessary. As may be conceived, and as was intended, 
these plasters, each time they were removed, tore out a quantity of 
hair, more or less considerable. The first applications were attended 
with cruel sufferings ; the agony became less and less severe as 
progress was made in the treatment. Nevertheless, the pain was still 
so great at a month's end, that children might be heard screaming 
dreadfully when the plaster was removed ; after the third month, the 
pain of the dressing became less intolerable." As a commentary on 
this barbarous proceeding, the Messrs. Mahon affirm, " that they saw 
a child die two days after having this horrible operation performed on 
its scalp." 

The Messrs. Mahon pursue a different process for withdrawing the 
hair in this disease. They cut it to the length of two inches, apply 
poultices to soften, and thorough washing with soap to remove the 
crusts, and then comb the hair repeatedly, in order to draw out all the 
loosened hairs. After this preparatory process is accomplished, they 
rub daily into the scalp, for about a fortnight, a moderately stimu- 
lating application, consisting chiefly of lime and subcarbonate of 
potash, 1 in the form of ointment, and continue washing and combing 

1 According to an analysis made by M. Chevallier, the remedies of the MM. Mahon 
are composed of slaked lime, subcarbonate of potash, and charcoal. They use three 
applications of different degrees of strength, and once a week they sprinkle a depilatory 
powder among tlie hair, which they subsequently comb out. 



DISEASES OF THE NAILS AND NAIL-FOLLICLES. 653 

as before. For the next three or four weeks, and until the cure is 
established, this treatment is pursued with longer intervals, no day 
being permitted to pass over without a thorough ablution. 

It is obvious that this treatment of the Messrs. Mahon, which has 
proved the most successful ever pursued, does no more than fulfil the 
local indications laid down at the commencement of the principles of 
treatment developed in this chapter. These gentlemen call their 
ointment "depilatory," but in this they fall into the popular error of 
regarding the hairs, which are really harmless, as irritants. Their 
system is simply a moderately stimulating plan, wanting, to give it 
perfection, the constitutional treatment above recommended. 

M. Petel has proposed, as an imitation of MM. Mahon's remedies, 
an ointment and powder as follows : 

R. — Sodse subcarb. gr. ix. R. — Calcis vivi, ^ij. 

Calcis vivi, jj. Carbonis ligni, gij. — M. 

Axungiae, ^ij. — M. 

The ointment is to be used daily, after washing, and after the 
removal of the crusts ; and the powder is to be sprinkled on the scalp 
with the view of causing the fall of the hair. 



CHAPTER XXIII. 

DISEASES AFFECTING THE SPECIAL STRUCTURE OF THE SKIN. 
DISEASES OF THE NAILS AND NAIL-FOLLICLES. 

The disorders of the nails and nail-follicles are referable to altera- 
tions in the disposition of the skin around the margin of the nail ; in 
the development, growth, color, and texture of the nails themselves ; 
and, to inflammation, suppuration, and ulceration of the matrix and 
adjacent soft parts. 

In reference to the first of these alterations, we sometimes meet 
with cases in which the epidermis of the margin of the nail-follicle 
remains attached to the surface of the nail, and advances with its 
growth, until the nail is more or less completely covered. This is 
termed pterygium unguis. When less complete, the epidermis is apt 
to break up into little bands, which curve back and project from the 
skin around the root of the nail, giving rise to much inconvenience, 
and often, from being accidentally torn, causing soreness and tender- 
ness of the skin. These little ragged bands of cuticle are called 
agnails, on account of the pain and suffering which they not unfre- 
quently occasion. At other times, instead of growing forward with 



654 DISEASES OF SPECIAL STRUCTURE OE THE SKIN. 

the nail, the cuticular margin of the follicle recedes, and exposes the 
root of the nails. This affection is rare, but has received the name 
of jicus unguium. Rayer remarks that he has observed it among 
curriers ; I have a few times seen it myself, where there existed a 
chronic state of inflammation of the nail-follicle. 

Abnormal development of the nails is evinced in the occasional 
congenital absence of those organs; in their disposition to fall from 
time to time, with and without apparent cause ; in their irregular 
shape, their occurrence in greater number than natural, and in their 
abnormal position. The congenital absence of one or more of the nails 
is rare, but such cases are sometimes seen. Of the fall of the nails 
(lapsus unguis), k i have met with several examples, in which they 
were regularly shed; new nails being formed beneath, while the old 
ones were becoming loosened previously to falling off. This morbid 
peculiarity has been recognized by pathology, and has received the 
name of alopecia unguealis. More frequently, the fall of the nail 
results from inflammation of the matrix, as in scarlatina, syphilis, 
&c. ; and chronic inflammation of that organ, induced by local injury, 
burn, frost-bite, or other causes. Faulty shape of the nails, deformitas 
unguium, usually results from some disturbance of the secreting 
organ, the matrix, and sometimes from mal-nutrition, the consequence 
of deficient innervation, as in cases of paralysis. The nail may be 
unnaturally long or short, too broad or too much coflrpressed at the 
sides, too prominent, too flat, or too much arched or curved, arctura 
unguis. Sometimes the nail projects longitudinally, like the angular 
ridge of a house-top, and, when thickened, has rather the character of 
a talon than a nail ; sometimes it is concave on the surface, the direc- 
tion of the concavity being longitudinal, or horizontal ; and some- 
times, it is remarkable for its curve over the end of the finger, as in 
the ungues adunci, the arched and hooked nails so frequently seen in 
scrofulous and consumptive persons. Now and then we meet with 
supernumerary nails, generally in the form of two rudimentary nails 
blended together, evincing an intention of bifurcation of the finger 
or toe. And, occasionally, from some accident of 
Fig. T. development, we find the nail occupying an abnor- 

mal situation. The most remarkable illustration 
of the latter phenomenon is the production of a 
nail-like growth on the extremity of amputated 
fingers; even on the stumps of the first and 
second phalanges, where no rudiment of the ori- 
ginal matrix can have existed. 

Abnormal growth of the nails is illustrated, 
sometimes by deficient growth ; sometimes by 
growth in excess; and sometimes by unnatural 
growth. I have met with instances in which 
the growth of the nail has been so remarkably 
slow, that they might almost be taken for examples of complete 
arrest of growth. In other cases, the growth of the nail has been as 
striking for its rapidity or extent ; the nails sometimes grow to be of 




DISEASES OF THE NAILS AND NAIL-FOLLICLES. 655 

enormous size in Barbadoes leg ; and a case of extraordinary growth 
of the nails is recorded by Saillant, as occurring in a woman named 
Melin, and named from this peculiarity the "femme aux ongles." 1 
Where there has been neglect, as in bedridden and elderly persons, 
the nails are apt to attain an extravagant size. I have in my pos- 
session several toe-nails of this kind, measuring two and three inches 
in length. Rohout, in a paper addressed to the Academy of Sciences 
of Paris, has described a toe-nail which measured nearly five inches. 
Rayer mentions two great toe-nails which measured three inches, 
and were spirally twisted like the horns of a ram ; and Saviard 
" saw a patient in the Hotel Dieu, who had a horn instead of a nail 
upon each great toe." Musseus, in his Dissertatio de Unguibus Mon- 
strosis, records a case of unnatural growth of the nails, in which 
those organs resembled talons, and were five inches in length ; while 
similar horny growths were developed on the skin of other parts of the 
body. 

Discoloration of the nails is met with in some diseases of the 
skin affecting the matrix of the nails, as in eczema and lepra ; and it 
also results from injury, as in ecchymosis beneath the nail, the conse- 
quence of a bruise, ecchymoma unguis. Not unfrequently the nail is 
speckled with small roundish white spots, selene unguis, figuratively 
named by the ancient writers, jiores unguium ; and, by the moderns, 
less elegantly termed mendacia, or lies. These spots are more com- 
mon in the nails of children than adults, and result from some 
slight injury done to the matrix of the nail during the progress of 
growth. 

Abnormal texture of the nail may present itself in the threefold 
form of, increased thickness, altered density, and altered smoothness 
of the nails, constituting the state of disease known as degeneratio 
unguium. Or the matrix of the nail may be the subject of inflamma- 
tion, suppuration, and ulceration, constituting onychia. We may now 
proceed to the consideration of these two forms of disease. 



degeneratio unguium. 
Defcedatio unguium. Scabrities unguium. 

The nails sometimes acquire an excessive degree of thickness, and 
the increase of bulk is accompanied with a yellow and dirty discolora- 
tion, the nail resembling horn, rather than its own natural texture, 
both in color and density. In this state it is not uncommon to find 
the nail separating from its matrix, and a dry, whitish, broken sub- 
stance collected in large quantity beneath it. Two such cases are now 
before me, in which the greater part of the fingers of both hands are 
affected in this manner. 

In another case, also under my observation at the present time, the 
nails are reduced to a mere film, and so soft and brittle in texture, that 

1 Saillant, M6moire sur la maladie de la femme dite aux ongles. Paris, 177G, 8vo. 



656 



DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 




they split and break with the slightest pressure, mollities unguium ; 
the texture of the nail is healthy, but its quantity defi- 
es- V. cient, and with the absence of quantity there is also, as 
a matter of course, an equal defect of firmness and 
tenacity. This state of the nails is a subject of much 
annoyance to the lady who is the sufferer from the affec- 
tion ; the ends of the nails are always ragged and bro- 
ken, they catch in her clothes and in almost every- 
thing she touches ; and when they are torn, they occa- 
sion bleeding and soreness of the matrix. , Sometimes 
the nails are brittle from a morbid alteration of texture, 
being converted into a white earthy matter which breaks 
up into shapeless granules on the application of a slight 
degree of pressure. 

Another change in the nails for which I have been 
several times consulted, is a fibrous state of those organs, 
which appear to be made up of a thick stratum of fibres, 
closely packed together, but becoming loosened here and 
there, so that separate fibres are met with on the sur- 
face. The surface of the nail is necessarily rough, rag- 
ged, discolored, and marked by numerous dark longitu- 
dinal lines ; and, besides being very unsightly, adheres 
like a burr to any rough material with which it comes in 
contact. 

Another variety of degenerated nail has the appear- 
ance of being eroded, or worm-eaten, tinea unguium, and 
sprinkled over more or less abundantly with hollow pits. 
This state of the nail, like the preceding, is very un- 
sightly, and the sufferer applies for relief, rather on 
nred state of the account of the ugliness of appearance^, than from any 
naii, m degen- rea j i nconven i ence# Unhappily, medicine can afford very 

eratio unguium; ... . rr »' " 

fissure unguium, little aid in these cases. 





A. B. C Fore- 
finger, middle, 
and ring finger, 
showing the bro- 
ken and disfig- 



ONYCHIA. 

Onychia is an inflammation of the matrix of the nail, sometimes 
confined to that structure only, but more frequently involving the 
immediately surrounding soft parts. The inflammation is succeeded 
by suppuration, and ulceration to a greater or less extent, the produc- 
tion of granulations of large size and unhealthy texture, of a fungous 
character, and an ichorous, sanious, and fetid discharge. The inflam- 
mation is sometimes superficial, sometimes extends to the deeper parts ; 
sometimes terminates in the loss of the nail, or a part of the nail ; and 
sometimes runs on to disease of the periosteum and bone. It is always 
a painful, and sometimes a troublesome and rebellious disease. 

Onychia may be partial, that is, may attack a single nail only, or 
it may affect a greater number ; it may also involve a part or the 
whole of the nail in destruction. It may occur along the edge of the 
nail, or at its root ; and it may be either acute or chronic in respect 
of its progress. 



DISEASES OF THE NAILS AND NAIL-FOLLICLES. 657 

It varies also according to the cause which shall have given rise to 
it ; whether that cause he one of external injury, as a bruise, a splinter, 
a puncture, or a foreign body lodged beneath the nail. Whether it 
shall have been produced and kept up by the pressure of the side of 
the nail against the soft parts, giving rise to the growing mof the nail. 
Or whether its cause may be internal and constitutional, as that pro- 
duced by eczema, scrofula, or syphilis. 

In onychia resulting from external injury the treatment should be 
such as is applicable to a similar injury, when occurring in any other 
situation. . If pus be formed beneath the nail, the nail should be thin- 
ned by scraping until reduced to a mere film, and then it should be 
punctured to allow the escape of the matter ; the same manoeuvre is 
applicable to the relief of the inflamed matrix when swollen by con- 
gestion ; or to the removal of a foreign body lodged beneath the nail. 

Onychia from in-growing nail originates frequently, and indeed 
generally, in interference with the growth of the nail in length by 
contact with the boot or shoe. Prevented from growing forwards, the 
nail is apt to spread laterally, and the skin pressed forcibly against 
it, becomes inflamed ; the inflammation increases from clay to day ; or 
after much walking the skin becomes red, swollen, and painful, adding 
still further to the pressure; then suppuration takes place, next ulcera- 
tion, the production of fungous granulations and an unhealthy dis- 
charge. The medical management of this case consists in the with- 
drawal of the cause by rest and position ; then the removal of the 
offending border of the nail ; and the general relief of the inflamma- 
tion by scraping the whole surface of the nail, until it becomes thin 
and pliable, and capable of yielding to the swelling of the inflamed 
parts. 

Eczematous onychia is usually accompanied with eruption on other 
parts of the fingers and hands, and frequently on several regions of the 
body. It does not call for any special treatment, but usually gets 
well when the general eczema is relieved. 

Scrofulous onychia commonly attacks the nail-follicle, and the inflam- 
mation spreads to the whole of the skin immediately bordering the 
nail ; by degrees the entire end of the finger is inflamed and enlarged, 
and the nail looks as if it were sunk into a deep hollow, surrounded 
by a tumid border of a deep red or purplish hue. The finger has the 
appearance which is commonly denominated clubbed, and as the dis- 
ease advances, and fungous granulations spring up from the ulcerated 
surface, the nail is sometimes completely concealed from view. 

Syphilitic onychia has already been considered in the chapter on 
syphilitic eruptions ; like scrofulous onychia it may attack the follicle 
of the nail, and is not confined to the lateral border, as in the case of 
in-growing nail. It is always accompanied by other signs of syphilis, 
and frequently with syphilitic eruption in other regions of the body. 

Onychia maligna is the name assigned to a peculiarly obstinate and 
severe form of the disease, apparently of idiopathic origin. It begins 
in the follicle of the nail, and is attended with excessive pain, and the 
secretion of an offensive discharge. It is the malignant onychia, which 

42 



658 DISEASES OF SPECIAL STRUCTURE OF THE SKIN. 

sometimes extends so deeply as to affect the periosteum and bone ; and 
is often many months under treatment. 

The diagnosis of onychia is self-evident, the only disease with which 
it can possibly be confounded being panaris, or common whitlow. 
Whitlow, however, begins in the skin at the end of the finger, or in 
the vicinity of the nail, and does not attack the matrix ; it is simply a 
phlegmon in this situation ; but when of large size, or, in its com- 
mencement, attacking the skin close to the border of the nail, the pus 
not unfrequently extends beneath the latter. 

The causes of onychia have been already stated ; they are, direct 
violence or injury, continued irritation from in-growing nail, and the 
constitutional and specific affections, eczema, scrofula, and syphilis. 
The cause of onychia maligna must be referred to some general de- 
rangement of the constitution, probably mal-assimilation and cachexia. 

Treatment. — The medical management of onychia from external 
injury, must be the same as that for injury in other parts of the body, 
with the exception of reducing the thickness of the nail by scraping, 
which is applicable to every form of the disease, and paring the nail 
so that it may not press on the inflamed skin, and increase the local 
irritation. Thinning of the nail, besides rendering it pliable, also 
facilitates the evacuation of pus, or the removal of foreign bodies 
impacted beneath it. 

In onychia, from in-growing nail, the removal of the cause, the 
relief from pressure, complete rest, thinning and paring the nail, and 
the application, if necessary, of nitrate of silver to the exuberant granu- 
lations, are generally successful. Where a fetid discharge is secreted, 
the solution of the chloride of lime is a necessary part of the treat- 
ment in all cases of onychia, and is, besides, a useful stimulant. 
Other local remedies are, the benzoated ointment of oxide of zinc, an 
ointment of Peruvian balsam, the yellow basilicon ointment, and strap- 
ping with adhesive plaster. It is sometimes useful to introduce a 
piece of lint, either dry, or coated with ointment, beneath the swollen 
and overhanging skin along the border of the nail. 

The constitutional forms of onychia call for a treatment adapted to 
the particular disease of which they are a part, whether eczematous, 
scrofulous, syphilitic, or malignant. And constitutional remedies 
mnst be made a leading part of the general management. The best 
local application in eczematous onychia is the benzoated ointment 
of oxide of zinc. Scrofulous onychia will require gently stimu- 
lating remedies, after the primary heat and inflammation have been 
subdued by cooling lotions, fomentations, and water-dressing, or 
poultices. For the syphilitic onychia, besides local antiphlogistic 
treatment as long as inflammation continues, the applications should 
consist of mercurial ointments. But this form of onychia will always 
yield to constitutional means. Onychia maligna calls for the use of 
alteratives and tonics ; and severe local treatment is sometimes re- 
quired, such as caustics, the actual cautery, and avulsion of the nail. 



HISTORY OF THE ITCH- ANIMALCULE. 659 



CHAPTER XXIV. 

HISTORY AND DESCRIPTION OF THE ITCH-ANIMALCULE. 
ACARUS SCABIEI. 

A popular knowledge of the existence of the itch-animalcule is 
probably coeval with the first development of scabies in the human 
race, since we find that the earliest writers mention it as possessing a 
popular synonym. Our dictionaries afford us similar information, and 
most observers have noticed the fact that a living creature is commonly 
extracted from the bodies of those affected, by members of their own 
class, and by fellow-sufferers. 

The earliest scientific information relative to the itch-animalcule 
that we find recorded, dates as far back as the time of Aristotle, 350 
years before the Christian era. For we .are informed by Moufet, in 
the commencement of his chapter, " De syronibus, acaris, tineisque 
animalium," that Aristotle was acquainted with these syrones, a 
statement which he precedes by a reproof to Thomas a Veiga for 
making an assertion to the contrary. For, says he, " Syronem anti- 
quitate ignotum fuisse Tho. a Veiga falso memorat, nam ipsum axaptdwv 
Aristoteles vocat." (5 Histor. Animal., cap. 32.) 

That the itch-animalcule was well known to the Greeks may also 
be inferred from the names siro and acarus by which it is designated, 
for, according to Moufet, both of these terms are derived from the 
Greek language. " Syrones item dici videntur, dnd too aup8-qv, ipnetv quia 
tractim sub cute repunt." And again he observes, " to yhp axapes, teste 
Polluce et Suida, exiguum ilium dicitur, quod ab exiguitate non pos- 
sumus xeipac, id est, dividere." 

The Arabians were also acquainted with the animalcule at a very 
early period, for we find Abinzoar, in the twelfth century, thus 
speaking of them : " Syrones Assoalat et Assoab dicti, sunt pedicelli 
subter manuum crurumque et pedum cutem serpentes et pustulas 
ibidem excitantes aqua plenas : tarn parva animalcula, ut vix visu 
perspicaci discerni valeant." 1 But Moufet expressly tells us that 
Abinzoar is the only one amongst the ancient authors who shows any 
knowledge of scabies and of the proper method of treating it, " Horum 
nullus antiquorum meininit proctor Abinzoar qui morbum hunc vidit et 
curationem ejus recte instituit." 

The Romans named the itch-animalcule pedicellus; and from several 
quotations made by Moufet, we learn that the Roman physicians were 
well acquainted with it. 

1 Moufet, Theatrum Insectorum, p. 266. 



660 HISTORY OF THE IT CH- A NIM A L C UL E. 

Scaliger, in his letter to Cardanus in 1557, remarks that the acarus 
is globular in form, and so minute as to be scarcely perceptible. The 
Turinians, he observes, called it scirro, and the Gascons, brigant. The 
little creature lives in canals which it burrows in the epidermis, and 
when taken out and placed upon the nail, exhibits a certain degree of 
movement, which is much increased by the warmth of the sun. When 
crushed between the nails, a slight noise is heard, and a small quantity 
of watery fluid is perceived. 1 

Gabucinus observes, " Ad nostra tempora quoddam supplicii genus 
indomita foeditate pervenit; in manibus exilis quidam pedicellus, lente 
minor, sub cute serpit." 

Ingrassias, after referring to the statement of Abinzoar, observes, 
" Excoriata cute ubi minimus ille jonthus varulusve, cujusdam suda- 
minis instar apparet, exeunt animalcula viva, tarn parvuncula ut vix 
possint videri." 

Jobertus very aptly compares them with moles, but unfortunately 
invalidates this testimony by supposing them to be the hidden cause 
of porrigo ; for, says he, " nascuntur saepe in capite et pilorum radices 

exedunt, quos Gl'ceci rptyvfipcuTouq, rpiyoffprny-raq, arjraq, rpcyofiopouq, tineas 
peculiari nomine appellant." 

Aldrovandus, also, in 1596, draws attention to the minute size of 
the 'pedicello^ its resort in burrows beneath the epidermis, and its exci- 
tation of vesicles. He* remarks that we need sharp eyes and a good 
light in order to perceive it. 

Moufet, in his famous work already referred to, the TJieatrum 
Insectorum, published in 1634, by Sir Theodore May erne, after the 
death of its author, but commenced during the preceding century by 
Wotton, Gessner, and Penn, gives the first account of the itch-animal- 
cule published by an English writer. In this volume we find recorded 
a very complete description of the creature, and the most important 
facts with regard to its habits are accurately noted. In truth, little 
is known on the subject, at the present day, that was not already 
pointed out by that distinguished writer. In reference to their size 
and form, he observes, " Syronibus nulla expressa forma (ut recte 
Scaliger notavit) preterquam globi : vix oculis capitur magnitudo 
tarn pusilla, ut non atomis constare ipsum, sed unum esse ex atomis 
Epicurus dixerit." In another place he remarks, "Animalculum 
est omnium minutissimum ;" its color, "est albicante, capite excepto ; 
propius intuenti nigricat, vel nigro parum rubet;" and it moves 
briskly when liberated from confinement, and stimulated by light 
and warmth. " Extractus acu et super ungue positus, movet se, si 
solis etiam calore adjuvetur." He remarks upon the burrowing 
habits of the creature, and the situation in which it is usually found, 
" Ita sub cute habitat, ut actis cuniculis pruritum maximum loco 
ingeneret;" and again, " Mirum est quomodo tarn pusilla bestiola 
nullis quasi pedibus incedens, tarn longos sub cuticula sulcos peragat. 
Hoc obiter est observandum, syrones istos non in ipsis pustulis sed 
prope habitare." He, moreover, rebuts the notion of their being 

1 Exercitatio 194; tie Subtilibus ; num. 7, 1557. 



OBSERVATIONS OF MOUFET — ETMULLER. 661 

allied to pediculi, and defends Aristotle against such an insinuation. 
" Neque syrones isti sunt de pediculorum genere ut Johannes Langius 
ex Aristotele videtur asserere : nam illi extra cutem vivunt, hi vero 
non : neque revera Aristoteles ullo quod sciam scripto inter pediculos 
acaros numeravit." His inference respecting their origin, drawn from 
their habitation, savors rather of the times than of the truth. " Illo- 
rum quippe proprium est non longe residere ab humore aqueo in vesi- 
cula' vel pustula" collecto : quo absumpto, vel exsiccato, brevi omnes 
intereunt. Unde colligimus, quemadmodum ex sero putrefacto exori- 
antur, sic eodem vicissim sustentantur." Moufet falls into the par- 
donable error, since repeated by several modern authors, especially by 
Linnaeus, of confounding the acarus scabiei with the acarus domesti- 
cus. Thus, he remarks, that the syrones are produced in decayed 
cheese and wax, and when found in these substances, as well as in 
leaves and dried wood, they are termed mites, " sed in homine ivheale 
wormes dicuntur, et Germanice, Seuren" 

In the year 1654, Augustus Hauptmann, a German physician, pub- 
lished a work on baths, 1 in which he speaks of the Acari or Sirones 
which he found in persons affected with scabies. These, he says, are 
in German called " Reitliesen;" they have six legs, and in appearance 
they resemble the mites of old cheese. To Hauptmann belongs the 
credit of giving the first figure of the animalcule; which is referred to by 
Bonanni, both in his own work and in his edition of Kircherius, in the 
following terms : " Monstrosam eorum figuram cum permultis et oblon- 
gis post tergum caudis depinget." 

Haffenreffer, in 1660, also a German physician, alludes to the 
acarus as a species of pediculus of very minute size, breeding between 
the epidermis and the derma. 2 

In 1682, a short notice of the animalcule, attributed to Etmuller, 
is given in the first volume of the Acta Eruditorum Lipsice. 3 In this 
account reference is made to Scaliger's observation of its globular 
form, and to the opinion entertained by Rohault 4 of its back being 
covered with scales : "Dorsum sit squammosum seu squamis cooper- 
tum." The author gives the following description of them : " Colore 
sunt albicante et pedibus exceptis, qui propius intuenti nigricare viden- 
tur, pedibus sex instructi sunt, binis utrinque mox juxta caput positis, 
quibus talparum ritu canaliculos sub cuticula agere, ut oblongos non 
raro, quasi sulcos, trahere, simulque molestissimum pruritum excitare 
videntur." The paper is illustrated with three figures, drawn with an 
object-glass of low power ; they are somewhat coarsely executed, but 
afford a tolerably fair representation of the general characters of the 
animalcule. 

During the following year, namely, in 1683, Giovanni Cosimo Bo- 
nomo published his letter to Redi, 5 which was translated into Latin by 

1 Dbralten Wolkcnsteinischen Warmen Bad und Wasser schatze, 8vo. Dresden. 

2 Nosodochium cutis an"ectU9. Ulmoe, 1660. 

3 For September, L682, p. 317. * Trac. Physic, par. i. cap. 21, 1798. 

6 Observazioni intorno, a pelicelli del corpo uraano del G. Cos. Bonomo, in una lettera 
al Fr. Redi. 



662 HISTORY OF THE ITCH-ANIMALCULE. 

Lanzoni, 1 in 1692. An abstract of this letter was read before the 
Royal Society by Dr. Mead, and published in the Philosophical Trans- 
actions 2 for 1702. Bonomo gives a more perfect account of the acarus 
scabiei than had hitherto existed. His attention was first drawn to 
the subject by meeting with the popular name of the itch-animalcule 
in his Vocabulario delV Academia della Crusca, followed by the ac- 
companying explanation : " Pellicello e un piccolissimo Bacolino, il 
quale si genera a Rognosi in pelle e rodendo cagiona un acutissimo 
pizzicore." He then betook himself to researches with the view of de- 
termining the truth of this definition, in which he was aided by his 
friend Hyacintho Cestonio, who informed him that he had seen "mu- 
lierculas propriis e scabiosis filiolis acus extremitate, nescio quid edu- 
cere, quod in laeve manus pollicis ungue, alterius manus pollicis ungue 
compressum, in ipsa compressione aliquem parvum sonum facere vide- 
tur, hoc autem educi a minutioribus tuberculis scabiosis, perfecta non- 
dum sanie scatentibus, vel ut vocitant immaturis ; mutua quod itidem 
charitate inter remiges et mancipia Balnei Liburnensis, si scabies in- 
festaret fieri, adnotavit." Having obtained one of the animalcules, 
Bonomo examined it with the microscope, and " found it to be a very 
minute living creature, in shape resembling a tortoise, of a whitish 
color, a little dark upon the back, with some thin and long hairs, of 
nimble motion, with six feet, a sharp head, with two little horns at the 
end of the snout." 3 

Bonomo gives two rude figures of the animalcule, which are inferior 
to those in the Acta JEruditorum, and must have resulted from the use 
of a bad microscope. He also delineates its "very small and scarcely 
visible white egg," and stands alone in this observation. Two remarks 
in Bonomo's letter are especially deserving of attention ; the first is 
his comparison of the siro with a little bladder of water; and the 
second, his observation relative to their habitation in vesicles, "imma- 
turis ;" both of which are invaluable as aids in seeking for the animal- 
cule. 

Morgagni, in his 55th Letter, book 4, contributes his evidence to 
the existence of the itch-animalcule and records a case in which he 
saw the creature himself. 

In 1691, Philip Bonanni, in his Observationes circa viventia quce in 
rebus non viventibus reperiuntur, as well as in his edition of the Rerum 
Naturalium of Kircherius, refers to the opinions of Bochartus, Kirche- 
rius, and Borellus. Kircherius found these minute creatures, " can- 
didi puncti similitudinem," when examined with the microscope, to be 
"animalia pilosa et prorsus urso similia." Borellus, he observes, 
" histrici similia facit ;" but this author, I am inclined to think, de- 
scribes the acarus domesticus, and not the acarus scabiei ; although he 
was evidently acquainted with the latter, since, in his Historiarum et 
Observationum Medico-physicarum, under the title of " Ulcera pedicu- 

1 Observationes circa humani Corporis Teredinem. In Miscell. Natur. Curios, for 
1692. 

2 Philosophical Transactions, vol. xxiii. p. 1296, pi. 283. 

3 Philosophical Transactions, abridged, vol. v. p. 199. 



OBSERVATIONS OF BAKER — WICHMANN. 663 

losa,' n he records an instance of vesicular affection apparently identical 
with scabies. Bonanni gives four figures of the animalcule, one from 
Bonomo's letter, two from the Acta Eruditorum, and one of his own. 
Concerning the latter he observes, " insectum hexapode, quod motu 
erat pigrum, colore livido, et raris setosis villosum." 2 In size it was 
about equal to a grain of sand ; and he concludes his description 
with the following question : " Unde nam istos animatorum semiato- 
mos erupisse judicabimus?" From the examination of his figure, 
which is of large size, and exceedingly rude, and from his statement 
that four of the little, animals were sent to him by Baldigianus, a 
professor of mathematics in Rome, and who had extracted them from 
the face of one of his scholars, it is quite evident that they are 
pediculi pubis, and not acari. Bonanni recopies the four figures from 
Kircherius. 3 

In 1744, 4 Baker, in a curious work, entitled the Microscope Made 
Easy, for the perusal of a copy of which I am indebted to my kind 
friend, Dr. Grant, remarks, " The microscope has discovered what, 
without it, could scarcely have been imagined, that the distemper we 
call the itch is owing to little insects under the cuticula, whose 
continual bitings cause an oozing of serum from the cutis, and 
produce those pustules and watery bladders whereby this disease is 
known." He then quotes the description of the animalcule, and the 
mode of finding and extracting it, given by Bonomo, and copies the 
two figures of this author, not forgetting the ovum. 

In 1762, Casal, a Spanish physician, in a work, entitled Medical 
Researches on the Asturias, referring to the burrowing and grubbing 
habits of the acari, remarks, " Vocantur aratores, et merito, arant 
enim semper inter cuticulam et cutem." 

In 1786, Dr. Wichmann, of Hanover, was induced to verify the 
prevailing opinion of the existence of an animalcule in connection 
with scabies, and the results of his labors are published in a volume 
entitled JEtiologie der Kraetze. 5 He found the zoological characters 
of the animalcule undecided, and the precise species infesting the skin 
in scabies undetermined. " Thus," he remarks, "of many naturalists, 
to name only a few of rank, Linnaeus has only tentacula, Schaeffer has 
antennas pediformes articulate, while Baron de Geer expressly says, 
they have no antennae, but two arms with joints, which resemble 
those of spiders, which have likewise no antennae." He alludes also 
to the opinion of Linnaeus, that the acari farinae might be con- 
veyed, in the powder used in dressing children, to their skins, and 
there colonized ; and he attributes to this error on the part of the 
great naturalist the assertion made by Professor Murray, 6 "that pre- 
vious to any appearance of pustules (in scabies), there is always a 
foulness of the juices, and that when this foulness has got a certain 
height, the acari of cheese or meal are induced to seek a nidus in the 
skin." Dr. Wichmann refers also to the omission of distinction of 

1 Obs. 20. 2 Fi^. 111. 3 Fig. 95. 

* This is the date of the third edition. 

6 8vo. 1780; and London Medical Journal, vol. ix. 17G8, p. 28. 

6 De vermibus in Lepra obviis. Gottingen, 1769, p. 9. 



664 HISTORY OF THE IT C H- ANIM A L CU LE. 

species by Pallas, 1 for that author remarks, " Acarus scabiei, acaro 
farinre est consanguineus." De Geer, however, distinguishes the two 
species very accurately, for of the acarus farinse he observes, "Acarus 
oblongus albus capite refuscente, peclibus conicis crassioribus sequa- 
libus;" and of the acarus scabiei, "Acarus subrotundus albus, pedibus 
rufescentibus brevibus ; posticis quatuor seta longissirna, plantis qua- 
tuor anticis fistulatis capitulo terminatis." The author points out the 
vesicles as the seat of habitation of the animalcule, but he observes, 
that " even before such a transparent vesicle is formed, we may 
often discover traces of the insect on the fingers or hands, in a reddish 
streak or furrow," and "it is even more usual to find it in these 
furrows than in the pustules themselves." The furrows he discovers 
only on the hands and fingers. Dr. Wichmann gives two figures of it, 
as examined with an object-glass of high power. These are very 
correct, and give a better idea of the little creature, as seen by that 
instrument, than any other delineations published. Like his pre- 
decessors, he makes no attempt to describe the zoological characters 
and structure of the animalcule. 

In 1805, Dr. Adams gives two excellent figures of the itch-animal- 
cule in a paper 2 addressed to Sir Joseph Banks, and read before the 
Royal Society in the month of April of that year. This paper is en- 
titled, An Account of the Acarus Siro, Acarus Exulcerans of Lin- 
naeus ; by some considered as the Itch Insect. The figures of the acarus 
which accompany this paper are superior to any that have been pub- 
lished either before or since, and are sufficient to identify the animal- 
cule completely with the acarus scabiei. The author's observations 
were made in Madeira, where, it would appear, the creature is ex- 
tremely common, and is called ogao, ougou, ougam. Dr. Adams gives 
no zoological description of the animalcule, but confines himself chiefly 
to the disease engendered by its presence, and to the mode of detecting 
the ogao. In the latter art he was instructed by an old woman, and 
he confesses himself to have been a dull scholar; but the results of 
his searches afford no better information than that which I have 
already adverted to, as contained in the Theatrum Insectorum of 
Moufet. The principal seat of the animal, says Dr. Adams, is a 
"reddish elevation" at the end of a "somewhat knotty" reddish 
line, extending from the vesicles for the distance of about a quarter of 
an inch. The author attributes to the animalcule a "power of 
leaping with a force not less than a flea. Such was the case with one 
whilst I was examining it under a convex lens." In this he is en- 
tirely mistaken; for the creature is deficient in the organization 
necessary for such an effort, and its sudden disappearance from the 
field of his lens is rather to be ascribed to some untoward movement 
occurring during the adjustment of his optical apparatus. Dr. Adams 
expresses himself unwilling to accord to Bonomo all the credit which 
that writer claims; and in reference to the discovery of the egg, 
remarks, " without suspecting the good intention of this writer, you 
will readily admit the uncertain discrimination of the egg of an 



1 Dissertatio de infestis viventibus, 1760, p. 2. 

2 Published in his work on Morbid Poisons, 4to., 1 



S07, p. 293. 



OBSERVATIONS OF ADAMS — GAL^S. 665 

insect, described by De Geer as about the size of a nit, but which, on 
placing it under a microscope, by the side of a nit, did not appear 
more than a fourth part of its bulk. For myself, I never could dis- 
cover what could satisfactorily be called an egg." 

Hitherto Dr. Adams has spoken of the ocao as being identical with 
the itch-animalcule of Bonomo and other writers, but in subsequent 
paragraphs he declares his belief that the disease engendered by the 
ougoes, and that of the itch, are perfectly distinct, and he founds this 
opinion upon the following data: 

1. The disease of ougoes is attended with considerable febrile dis- 
turbance, and sometimes with severe local symptoms. 

2. It is easily cured ; by extracting the animalcules, by the white 
precipitate ointment, or by the use of sulphur internally. 

3. It is liable to recur from the development of undestroyed ova, 
unless the remedies be continued for a month after the apparent cure ; 
and even then, if the disease be cured in the autumn, it is liable to 
return in the spring, because the animalcules remain torpid during the 
winter. 

4. It is always attended with vesicles which possess great uniformi- 
ty, and have each a red line ; whereas in itch the vesicles are variable 
in size. 

5. The natives of Madeira entertain a disgust for the itch, which 
they call sarna ; whereas the ougoes give them no discomfort. 

6. The dictionaries of all languages are opposed to the similarity of 
the affections, since they indicate a name for the animalcule distinct 
from that of the itch. 

7. John Hunter could never discover the itch-animalcule. 

Now, all these objections, cogent as they may have appeared to the 
author, must fall to the ground the moment that the animalcule is 
shown to be present in the itch, and to be the cause of that affection. 
Nor would it be difficult to prove, seriatim, that each of the objections 
above cited is unfounded. The figures appended to Dr. Adams's papers 
are so excellent, that I am inclined to assign to them a rank superior 
to those of Wichmann, although the object of the two authors is 
widely different, and scarcely admits of comparison ; for while the 
figures of Adams are intended to trace form and general character, in 
those of Wichmann there is a manifest endeavor to exhibit texture 
also. 

The year 1812 witnessed the performance of a remarkable scene in 
the memoirs of the acarus scabiei. M. Gales, Pharmacicn of Saint 
Louis, tempted by a prize offered by an unbeliever in the existence of 
the little animal, introduced the gentle stranger to the wondering gaze 
of the notabilities of Paris. The Academy applauded, the crowns were 
paid, and the pencil of the artist of the Muse'e Royale was called to 
perpetuate the juggle. lie drew to the life the common meal-mite ! 
(acarus farinsa). It is needless to say, that the statements put forth by 
M. Gales were, from beginning to end, a tissue of deceptions, and to 
have written such stuff as that contained in his paper is the best proof 
that he could never have seen the animalcule. M. Patrix played pan- 
taloon to M. Gales's clown. 



666 HISTORY OF THE ITCH- ANIMALCULE. 

The discovery of the treachery of M. Gales was not, however, made 
for a considerable number of years, when, with some difficulty, Raspail 
succeeded in proving the identity of the insect of Gales with the aca- 
rus farinae. The consequence of the exposure was universal distrust, 
and in this state the question remained, until a young student from 
Corsica, M. Renucci, in the year 1834, exhibited the veritable ani- 
malcule in the clinical theatre of Alibert, and demonstrated the method 
of discovering its lurking-place in the epidermis. 1 

The subject was next taken up by M. Albin Gras, a student of St. 
Louis, who has shown himself well qualified for the undertaking. He 
published a small treatise 2 in the autumn of 183-4, in which he gives 
a good summary of the knowledge of our ancestors relative to the 
animalcule, explains the manners and habits of the little creature, and 
details some excellent experiments made by himself, in reference to 
the mode of treatment of the disease. The habits of the acarus, when 
placed upon the skin, are detailed in a chapter of this volume, as also 
are M. Gras' experiments with medicinal agents on its powers of 
vitality. After giving a description of the animalcule inferior to that 
of M. Raspail, the author remarks : " If we observe the mode of pro- 
gression of the insect on the epidermis, we may easily assure ourselves 
that it does not bore its cuniculi in the manner of the mole, by means 
of its anterior legs, for the legs are not disposed to enable the creature 
to effect its object in this manner, but it lifts the epidermis by means 
of its flattened snout. The hairs upon its back aid it in this operation, 
for being directed posteriorly, all return on the part of the animal is 
rendered impossible." 

" In examining several sarcoptes beneath the microscope, we fre- 
quently perceive them to lay several small, white, oblong, and trans- 
parent eggs, the eggs, according to M. Duges, being one-third the length 
of the animal." " If we place an acarus on the epidermis, we perceive 
it to dodge about here and there, following by choice the course of the 
folds of the skin, and every now and then fixing itself upon the epider- 
mis, and raising the posterior part of its body." 

In 1834, Raspail published his Memoire comparatif sur V Ristoire 
naturelle de V Insecte de la G-ale, in which he details the history of 
modern discovery in France relative to the itch-animalcule, a narra- 
tive replete with misadventures, that the perusal of Moufet would 
have effectually prevented. In 1831, he had seen and delineated the 
acari scabiei of the horse, but it was not until three years afterwards 
that he was first shown by Renucci the animalcule of the scabies of 
man. After describing the epidermal cuniculi which are burrowed 
by the creature, he observes that the precise seat of the acarus is indi- 
cated by a white point. His description of the animalcule is the fol- 
lowing : It is white, scarcely half a millimetre in diameter, head and 
feet reddish and transparent, and it is invested by a covering which is 
hard, dense, and resisting. Its abdomen is flat and smooth ; the dorsum 

1 Some account of M. Renucci's mode of procedure will be found in the Gazette des 
Hopitanx, and Gazette M<klicale for 1 834. 

2 Recherches sur TAcarus, ou Sarcopte de la Gale de l'Homme. Par Albin Gras. Paris, 
Octobre 11. 1834. 



OBSERVATIONS OP RASPAIL. 667 

presents three prominences, one, of very large size, in the middle ; one, 
next in size, over the abdomen ; and one near the head. Along the 
lateral border of the creature, the dorsal and ventral surface join like 
the carapax and plastrum of a tortoise, and the resemblance to the 
shell of this animal is increased by the projection of the head and ante- 
rior legs from the space between the carapax and plastrum in front, 
between which they appear capable of retraction. The head is pro- 
vided with two large eyes, placed laterally; it is surmounted by four 
antennae, which are disposed in two rows between the eyes ; the trunk 
is folded beneath the head. The anterior legs have four joints, and a 
haunch-piece at the base of each ; they are terminated by a stiff ambu- 
lacrum, furnished at its extremity with a sucker. The posterior legs 
have the same number of pieces as the anterior, but are not more than 
one-fourth their length, and scarcely project beyond the abdomen. 
Each leg is terminated by a long hair in place of an ambulacrum. The 
anus projects, more or less, from the posterior border of the carapax, 
and is bounded by two short parallel hairs on each side. The carapax 
and plastrum are horny in texture ; the former is surmounted by stiff 
horny hairs, disposed in a certain order, two rows passing backwards 
from the centre to each side of the anus, and two forwards to each side 
of the head. The structure of the carapax is reticular, the meshes 
extending transversely. 

The figures accompanying this excellent description of the animal 
do great injustice to the text ; they are inferior to those of Adams, 
and also to those of Wichmann, neither of which appear to have been 
known to the author ; while he .praises the figures of De Geer, which 
are inferior to both. 

Besides the authors above referred to, some account of the acarus 
scabiei will be found in Schenkius, Obs. 676 ; in Rosenstein, on the 
diseases of children ; Pallas, De Infestis Viventibus, 1760 ; Sauvages, 
Maladies de la Peau ; Miscellanea Curiosa, 1692 ; Annales des Sciences 
d' Observation, vol. ii. p. 446, vol. iii. p. 298, 1830 ; Lancette Frangaise, 
Aout, 1831; Bulletin de Therapeutique, vol. vii. Journal des Connais- 
sances Medicales, Septembre 15, 1834. And for the comparative his- 
tory of the animalcule, Walz, De la Gale de Mouton. 

Linnaeus, from an imperfect acquaintance with the acarus scabiei, 
has been the cause of much of the confusion and obscurity which have 
involved the history of this animalcule. He places acarus in his 
order aptera, and gives the following as the characters of the genus : J 

Os proboscide carens, haustello vagina bivalvi, cylindrica, palpis 
duobus compressis, aequalibus, haustelli longitudine. 

Oculi duo ad latera capitis. 

Pedes octo. 

Tentacula duo, articulata, pediformia. 

In the first edition of the Fauna Suecica? Linnaeus describes the 
animalcule under the specific designation of " acarus humanus sub- 
cutanem." In the second edition 3 he considers the acarus humanus 

1 Systems Nature, 1767. 

2 Entornolo^ia Faunae Suecicoe. Villers's edition, 1789. No. 1194. 
8 Anno 1701. No. 1979. 



668 HISTORY OF THE ITCH-ANIMALCULE. 

subcutaneus as belonging to the same species as the flour-mite and 
checse-mite ; and in the Sy sterna Natures, observes, " Inter sirones 
Farinae, Scabiei, Phthiseos, Hemitritaei vix etiamnum reperiri alias 
differentias quam a loco petitas ;" while he admits the itch-animalcule 
as a new species, under the name of " acarus exulcerans." The specific 
characters of the two species he thus indicates :' 

" Acarus siro. — A. lateribus sublobatis, pedibus quatuor posticis 
longissimis, femoribus capiteque ferrugineis ; abdomine setoso. 

" /3. A. humanus subcutaneus. 

" Habitat sub cute hominis scabiem caussans ubi vesiculam excitavit, 
parum recedit corporis rugis secutus, quiescit iterum et titillationem 
excitat ; nudis oculis sub cuticula delitescens observatur ab adsueto 
acu facile eximitur, ungui impositus vix movetur, si vero oris calido 
halitu affletur agilis in ungue cursitat. 

" Descriptio. — Minimus, magnitudine vix lendis subrotundus, capite 
vix conspicuo, ore ut et pedibus rufis sive testaceis ; abdomen 
ovatum hyalinum ; in dorso duplici linea lunari seu pari linearum 
fuscarum recurvatarum notatum et quasi lobo utrinque. 

11 Acarus exulcerans. — A. pedibus longissimis setaceis ; anticis duobus 
brevibus. 

" Habitat in scabie ferina,, cujus caussa est." 

In the Entomoloyia Faunas Suecicce of Linnaeus, edited by Villers, 2 
the editor retains the above " Descriptio" in connection with acarus 
siro, but the " Habitat" he transfers to acarus exulcerans, commencing 
it thus : " Habitat in scabie ferina, sub cute hominis." To this he adds 
the observation of Fabricius, " Acaro sirone minor et distinctus et forte 
acaro exulcerante non diversus." Then follows the "Descriptio. A. 
albus, diaphanus ; corpus rotundatum, scabrum, nigro non lineatum 
uti acarus siro." The editor concludes with two remarks from his 
own pen: " Obs. 1. In Fauno Suecica, ed. 1, acarum farinse et scabiei 
separaverat Linnaeus, postea conjunxit, sed DD. Geoff., Fab., De Geer, 
pro diversis speciebus rite habuerunt ; ergo vere distincti. Obs. 2. 
Scabiei certe hie acarus caussa est." 

In the 13th edition 3 of the Systema Naturae, the acarus siro, com- 
prising the meal-mite and cheese-mite, is separated from acarus scabiei, 
but the acarus exulcerans is retained. The specific characters of the 
acarus scabiei are thus stated : 

" Acarus scabiei. — A. albus, pedibus rufescentibus ; posterioribus 
quatuor seta longissima. 

" Habitat in ulceribus scabiosorum, cutis rugas sequendo penetrans, 
titillationem excitans ; utrum causa, an potius, symptoma mali ? Sirone 
multo minor." 

Of the acarus exulcerans, Linnaeus remarks, " Habitat in ulceribus 
scabie ferina laborantium. An satis distinctus ab A. scabiei ?" 

In the Amoenitates Academical 4 the following passages, which are 

1 Fauna Suecica. Editio altera, auctior, 1761, Nos. 1975, 1976. 

2 Anno 1789. 

3 Edited by Gmelin, anno 1788, vol. v. 

4 Miraculo Insectorum. By G. E. Avelin. Upsal, 1752. Amoenitat. Acad., vol. iii. p. 3.33. 



OBSERVATIONS OF LINNAEUS — FABRICIUS. 669 

deserving of notice, occur. The first conveys the best idea of the 
seat and appearance beneath the cuticle of the acarus that I have met 
with in any writer ; the latter puts forth the unfortunate observation 
which led Linnaeus into error with regard to the classification of the 
itch-animalcule. Speaking of the vesicles, the writer observes, " Parum 
vero ab ilia in ruga cutis punctum quoddam fuscum quod nondum in 
vesiculam se extulit, fit tamen duobus diebus progressis; acus aculeo 
lens minima eximitur, quae ungui imposita et halitu oris afflata, in 
ungue cursitat. Oculis armatis ulterius appareat insectum hoc octo 
habere pedes, setas quasdam in dorso et acarum esse jam allatum." 
" Si mater aut nutrix infantem farina cereali, in qua acari saepissime 
habitant, adsperserit, infans in ea parte primo et toto tandem corpore 
scabie laboravit." 

In Sweden, Linnaeus remarks that the itch-animalcule is named 
Klamask. 

Schaeffer also describes the animalcule in his Elementa Entomolo- 
gice, in 1766. 

Baron de G-eer was thoroughly well acquainted with the itch-ani- 
malcule, and has left an admirable description of the creature, as well 
as two excellent figures. 1 The latter, however, are not equal to the 
description. He points out the error of Linnaeus with regard to clas- 
sification, and expresses his conviction of the identity of acarus scabiei 
and acarus exulcerans. The specific characters of the acarus scabiei 
he states to be as follows: 

" Acarus subrotundus albus, pedibus rufescentibus brevibus ; pos- 
ticis quatuor seta longissima, plantis quatuor anticis fistulatis capitulo 
terminatis." 

The capitulum in this definition he speaks of as being "en forme de 
vessie;" and in reference to scabies he observes, " Ces mittes sont 
meme l'unique cause de cette vilaine maladie." 

Fabricius, 2 in his Systema Entomological, places the acarus in the 
order antliata, which he characterizes as possessing " os, haustello, sine 
proboscide." The characters of the genus he thus designates: 

"Acarus. — Haustellum, vagina bivalvi, cylindrica ; palpi duo longi- 
tudine haustelli." To which, in the amended edition of 1794, he adds, 
"antennae filiformes." 

With regard to specific characters, Fabricius adopts the definitions 
of Linnaeus, and admits two species as inhabiting the skin of man, 
namely, the acarus siro and the acarus exulcerans. Of the former he 
remarks : " Habitat in caseo, farina" diutius asservatis, cutem hominis 
rugas secutus penetrat, vesiculum et titillationem excitat. Caussara, 
nee symptoma morbi esse evincunt observata analogia cum Gallis 
contagium cura." 

And of the latter : "Habitat in scabie fcrina." 

In the Fauna Groenlandica* the same author observes, with regard 
to acarus siro : " Habitat in vesicula scabiei Grcenlandorum, qui ilium 

1 Memoire pour servir it l'histoire ties insectes. Vol. vii., 1778, p. 94, pi. 5, figs. 
12-14. 

2 Johannes Christ. Fabricius. Ed. 1775, p. 813. 3 Anno 1780, p. 221. 



670 HISTORY OF THE ITCH- AXIM ALC ULE. 

acu apte eximere scientes, mihi miranti, ut vivum animal incedentem 
ostenclerunt. En Groenlandos Entomologos." " Varietatem farinse 
quidem etiam in farina mea vidi : an vero in Groenlandia domi habeat, 
incertus sum dum Groenlandi farinaceis non utuntur." He remarks, 
also, that in Greenland the animalcule is named " OJcoJc," and that in 
the natural history of Bomares it is termed " Scab-orm." 

In the Entomologia Systemica, emendata, 1 Fabricius adopts the opi- 
nion of De Geer with regard to the identity of the acarus siro with 
the acarus domesticus, or cheese- and meal-mite, and admits the itch- 
animalcule as a distinct species, with the following characters : " Acarus 
scabiei. Albus, pedibus rufescentibus, posticis quatuor longissima." 
It is, he continues, "multo minor et distinctus ab acaro sirone." He 
observes, also, that this species corresponds with the acarus exulce- 
rans, and quotes a passage from Linnaeus to the same effect. 

Muller, in his Prodromus Zoologice Danicce, 2 adopting the early 
classification of Linnaeus, treats of the itch-animalcule under the 
designation of acarus siro. In Denmark, he observes, the creature is 
called Krid-orm, Ring-orm, and Meel-mid. The latter term, which, 
translated, would be meal-mite, indicates the popular extension, or 
possibly the popular origin, of the error of the great Swedish natu- 
ralist. 

Latreille established the itch-animalcule as a new genus under 
the name of Sarcoptes hominis, with the following description : Body 
apterous; no distinction of head or segments; manducating organ 
prominent, without apparent palpi; eight short legs. Subsequently, 
however, on the occasion of the memorable juggle of Gale's, Latreille 
omitted the genus altogether. 

The existence of the acarus scabiei is without question. I have 
extracted as many as twenty from their retreat at a single sitting. I 
have placed them on a slide of glass, and seen them run; and after 
the business of the day has been over, I have examined them with 
the microscope and found them still active, living for several hours 
after my examination. I have already stated that I regard them as 
the unique cause of scabies, and as a necessary feature in the 
diagnosis of that disease. 

When examined with the naked eye the acarus looks white and 
shining, globular in form, and very aptly resembling the little 
bladder of water of Bonomo. There is no difficulty in extracting it 
from the skin ; the cuniculus is seen without difficulty ; the end of 
the cuniculus is perceived to be a little raised, while a reddish brown 
semilunar speck is seen beneath it. As soon as this little eminence of 
epidermis is lifted, if the end of the needle or pin with which the 
operation is performed be examined, the minute, white, and shining 
globe will probably be observed attached to the instrument. If there 
be no such object, the point of the needle placed again beneath the 
raised capsule of epidermis will pretty certainly draw it forth. This 
facility of extracting the little creature is due to its great power of 
clinging to any object with which it comes in contact. 

1 Anno 1794, vol. iv. * Otho Fredericus Muller. Anno 1776. 



OBSERVATIONS OF LATREILLE. 671 

When the acarus is seen running upon the surface of a plate of 
glass, it may be perceived that its anterior margin presents a dusky 
tint of color, and the examination of this part of the creatur.e with the 
microscope brings into view a head not unlike that of a tortoise, and a 
pair of large and strong legs on each side of the head. These organs 
are encased in a moderately thick layer of chytine, and have conse- 
quently the reddish-brown tint of the cases of certain insects, or of 
the bright part of a thin layer of tortoise-shell. Proceeding with our 
examination, we perceive the general outline of the animal to be sub- 
rotund, the antero-posterior predominating very little over the trans- 
verse diameter ; the anterior part of the creature being broad, and 
the posterior somewhat narrower, and semicircular. The ventral 
surface of the acarus is flat, and occupied by the head and eight legs; 
the dorsal surface is arched, uneven, and covered by numerous spines ; 
and projecting backwards from the posterior segment of the animal 
are twelve hair-like filaments, some long and others short. 

With the view of determining the size of the acarus, I measured 
ten specimens, and found them vary between y i ? and fo of an inch 
in length, and between 3^3 and ^ in breadth. The following were 
the measurements of seven of this number : 

Length. Breadth. Length. Breadth. 

55 lhs 



T47 TSS 

TT3 T4T 

$4 T43 



77 TOtf 



Examined with a quarter or eighth of an inch object-glass, or with 
Powell's half inch, the case of the body of the acarus is seen to be 
composed of narrow plates, variously disposed with regard to the axis 
of the animal, but chiefly transversely, and resembling a coat of plate 
armor. The connecting membrane of these plates permits of a 
certain degree of movement between them. The dorsum of the 
creature is convex, but uneven, and exhibits upon its borders a 
tendency to division into a thoracic and an abdominal segment, the 
former being somewhat broader than the latter. Anteriorly the dorsal 
case terminates in a sharp border, which is scalloped, and forms a 
jutting roof of protection to the head, and each of the four anterior 
legs. Posteriorly, the case is somewhat deeply cleft, forming a 
groove, which corresponds on the ventral surface with the sexual and 
anal aperture. 

The dorsal surface of the creature is covered with tubercles, spines, 
and hair-bearing tubercles, regularly and very remarkably disposed. 
The venter of the acarus is flat, and the abdominal portion slightly 
convex. The posterior part of the latter is grooved upon the middle 
line, and furnished with an anal and sexual aperture, of considerable 
size. 

The head is an oblong cylinder, more or less obtusely pointed in 
front, flattened beneath, enlarging slightly laterally towards the body 
of the creature, and implanted by its posterior end into the angular 
interval left by the divergence of the anterior pair of legs. The 



672 HISTORY OF THE ITCH -ANIMALCULE. 

lateral enlargement towards the root of the head is the most suitable 
place for eyes ; but I have not as yet been able to detect those organs. 
The head. is surmounted by two rows of stiff hairs. The mouth is an 
oblong aperture situated upon the under surface of the head, and be- 
coming broad towards the root of the latter. Its borders are furnished 
with a thick fringe of mandibles, and the interior supplied at each side 
with a number of strong maxillae. The head is capable of elongation 
or retraction beneath the dorsal plate or carapax. 

The legs are eight in number, four being anterior, and four posterior ; 
the anterior legs are large and powerful, the posterior small. The 
anterior pair of legs are so large, so closely placed to the head, and 
directed so immediately forwards, as to deserve the appellation of 
arms. The next pair follow immediately on the preceding, but are 
directed outwards. The legs are conical in form, tapering, when 
extended, to an obtuse point, and composed of a hip-piece and three 
circular segments. The hip-pieces of the two anterior legs join at an 
obtuse angle, and form the limit of the root of the head. The point 
of meeting of these hip-pieces is the commencement of a sternal crest, 
which runs backwards on the plastrum for a short distance, and 
terminates by a rounded extremity. A similar crest is formed at each 
side by the junction of the hip-pieces of the anterior and. lateral leg, 
the crest being directed backwards and inwards towards the termina- 
tion of the sternal crest. Each of the annular segments of the anterior 
legs is furnished with three or four bristly hairs, which stand out at 
right angles from the segment. Moreover, the extremity of each 
anterior leg is provided with a tubular cylinder [tarsus] as long as the 
entire leg, and terminated at its extremity by a foot divided on its 
sole into five lobes. 

The head and four anterior legs are covered with a strong case of 
chytine, which presents the ordinary color of insect cases, namely, a 
brownish red. The plastrum is slightly tinted with a similar hue, 
but the three crests formed by the hip-pieces are, in virtue of their 
thickness, of a deep color. These are the red lines of Gras, Raspail, 
and others. The posterior legs have but a thin case of chytine, and 
are less deeply colored. The colored covering of the head and legs 
contrasts very strongly with the yellowish white of the body of the 
animal. 

The posterior legs spring from the posterior part of the thoracic 
segment of the animal, two on each side ; they are conical in form, 
composed of three segments, and each leg is connected to the body by 
means of a triangular and flattened hip-piece. Each posterior leg is 
terminated by a rudimentary tarsus and foot, and by a long, mem- 
branous, hair-like organ, which is directed backwards. 

I have already alluded to the cleft on the posterior part of the 
abdominal segment of the animal, and the papilla which bounds the 
anal opening posteriorly. A pair of hair-like filaments mounted on 
"short tubercles are found on each side of this opening, near the poste- 
rior margin of the abdomen. These four filaments, with the 'four 
hair-like organs of the posterior legs, and the four directed backwards 
from the lateral part of the thoracic segment, form the twelve hair- 



HISTORY OF THE STBATOZOON FOLLI CULOR U M. 67-3 

like filaments ■which are observed along the posterior margin of the 
animal. These filaments, together with the hairs, spines, and tuber- 
cles situated on the dorsum, serve most effectually to prevent the 
retrogression of the acarus along its cuniculus, while the anterior part 
of the creature is equally well organized for advance. 

I have not been able to distinguish any sexual differences between 
the animals I have examined. In a sketch before me is drawn a coni- 
cal projection in this region, but I have not as yet seen that appear- 
ance repeated. 

The ova I have seen ; and I have preserved a slide, on which there 
are two of these bodies. 

The internal organization of the animalcule is obscured by the large 
collection of adipose cells which form its superficial stratum. 



HISTORY AND DESCRIPTION OF THE STEATOZOON 
FOLLICULORUM. 

In the course of some researches directed to the investigation of 
the cause of acne, Dr. Gustav Simon, of Berlin, discovered an 
animalcule in the sebaceous substance with which the hair-follicles are 
so commonly filled, particularly on the face, and gave it the designa- 
tion acarus folliculorum. 1 Dr. Simon's researches have hitherto been 
directed principally to the cutaneous follicles of the nose, where he 
finds the parasite with astonishing frequency, even in cases where the 
skin presents all the characters of ordinary health. Of living persons, 
he detected the animal in three out of ten men in the sebaceous matter 
squeezed out by pressure from the follicles ; but in the dead he dis- 
covered them in almost every individual examined, the only excep- 
tions out of ten bodies being two newly-born children. The mode of 
examination in the case of the dead was by means of thin sections. 
The animalcules imbedded in the sebaceous matter are found in the 
hair-follicles near the outlet, their long axis corresponding with that of 
the follicle, and their heads being directed inwards ; in four instances, 
the head and part of the body of the little creature were lodged 
in a sebifcrous duct. In normal hair-follicles they are usually not 
more than one or two of these parasites ; in rare instances, three or 
four ; but where the sebaceous substance is concreted, their number 
varies from two to six ; in one case he found as many as eleven, and 
in another thirteen. They are tardy in their movements, but retain 
their vitality for a considerable length of time ; thus Dr. Simon found 
them moving after a confinement of eight and twelve hours between 
two plates of glass, and in one body they were found alive after the 
person had been dead for six days. 

The animalcule presents several forms, which correspond with 
stages of development. In the most common form, the creatura 
Fanes from 0.085 to 0.125 of a line (German) in length, and 0.020 of 

1 Miiller's Archiv., 1812, p. 218. Ueber eine in den kranken und norrnalen Haar- 
sacken des Menschen lebende Milbe. 

43 



674 HISTORY AND DESCRIPTION OF THE 

a line in breadth ; it has an elongated figure, a long thoracic portion, 
with four pairs of legs, and an abdomen three times as long as the 
thorax, and tapering gradually to an obtusely-pointed extremity. The 
head consists of two large palpi, and a proboscis situated between the 
two. The palpi are bi-jointed, and terminated by several small teeth- 
like processes. The proboscis, which is capable of elongation and 
retraction, resembles a long tube, upon which lies a triangular organ, 
having its narrow base directed towards the root of the former, and 
extending by its apex almost to the extremity of the proboscis. This 
triangular body consists of two bristles, lying side by side. The head 
is continuous directly with the thorax, without any precise line of 
demarcation. The legs are short, conical, and composed of three 
segments, and upon the latter is an appearance of plaits. The leg is 
terminated by three claws, one long, the other two short. From the 
anterior part of the basis of each leg a double line runs transversely 
inwards across the under surface of the thorax, towards the middle, 
where one of the lines passes forwards and the other backwards, serv- 
ing together to form a central longitudinal double line. The trans- 
verse lines are probably continued completely around the thorax. 
The thorax is highest at about the middle, and broadest at the point 
corresponding with the second pair of legs. The abdomen is marked 
by a number of transverse lines produced by a series of grooves or 
contractions, which give the margin a resemblance to a file. The con- 
tents of the abdomen are granular, and similar to those of pigment 
cells, and among these granules are several large transparent spots of 
a round, oval, and sometimes quadrate form, like globules of oil. The 
tail is free from granules. 

A second form was remarkable from having the abdomen once 
only, or one and a half times longer than the thorax. The abdomen 
is more or less obtusely pointed posteriorly, and marked by the cha- 
racteristic transverse lines. 

In a third form, the abdomen is very short and acutely pointed. 
The thorax is broad, and there are no transverse lines on the abdomen. 

In a fourth form, the whole animal is remarkable for its slender 
figure ; the abdomen is very long ; there are only three pairs of legs, 
no transverse lines on the abdomen, and its granular contents are 
more lightly tinted. 

To what part of the animal kingdom does the parasite belong ? asks 
Dr. Simon ; and this question he refers to an eminent entomologist of 
Berlin, who returns him the following answer : The animal is clearly 
not an Helminthus, but its entire organization, and especially the 
gnat distinctness of its different pairs of legs, betoken it to belong 
to the great division Insecta, of Linnseus. Of this extensive group, 
the parasite before us appertains to the class Arachnida, for there is 
no separation between the head and thorax, there are no antennas, and 
it has four pairs of legs. Judging from the form of its mouth it 
should belong to the order Acarus. The proboscis is the under lip 
lengthened out, a form which this organ assumes in all mites. The 
two bristles lying on the proboscis are the mandibles, and the pair of 
two-jointed organs lying by the side of the proboscis are the maxillary 



STEATOZOON FO LLICULOEUM. 675 

palpi. The different forms in which the creature has been seen are 
stages of development. In the early state of the mite, the presence 
of three pairs of legs is a common character. The lengthened form 
here principally described is the second stage of development, and 
those with shorter abdominal segments represent later periods. It is 
therefore probable, that in the fully developed stage, the abdomen is 
lost altogether, and we are inclined to believe that this last stage is 
not as yet known to observers. The distinctions of genus and sex 
are, consequently, not yet practicable. 

In general, such a metamorphosis as the one here described does 
not occur in the mite, for these creatures retain the form, even 
although an additional pair of legs have to be developed, which they 
possessed on first breaking from the egg. On the other hand, Hartig 
has observed and described in the mite of the pinegall (Oribata geni- 
culata, Latreille) a metamorphosis precisely analogous to that of the 
animalcule before us. 

These animalcules cannot be metamorphosed into parasitic mites, 
for the itch-mite and mange-mite have distinctly segmented legs with 
joint-lobes (Heftlappchen), and no metamorphosis, since they issue 
from the egg already provided with four pairs of legs. Earlier, some 
relationship might have been inferred between this animalcule and 
the bird-mite (Dermanyssus), which, in its young state, has only six 
legs ; but the worm-like form of our animalcule in its early stages, 
and the remarkable shortness of its legs, render comparison between 
them impossible. • 

The animal found by Donne* in the mucus of the vagina (Tricho- 
monas vaginalis), which this observer considers to belong to the 
Infusoria, and, according to others, is more nearly related to Acarus, 
differs in many points, according to Donne's description and figure, 
from the acarus of the hair-follicles. For instance, it is often not 
more than double the size of a blood-corpuscle, and at most T ^ v of a 
line long; it has a round or elliptic-shaped body, with a whip-like 
appendage in front, and along one of its sides several fine fibres. 1 

Again, as the animalcule of the hair-follicles has not yet, as we 
conjecture, been seen in its perfect shape, it is possible, although little 
probable, that this last stage of development may correspond with 
some already known mite. In no case, however, could the animal- 
cule, for the before-mentioned reasons, become one of the ordinary 
para sites of the human skin ; but this creature must present the 
remarkable peculiarity of living within the human body in its young 
state, and in its perfect state of living external to it. Further 
researches may serve to establish this question ; in the meantime, 
however, I will designate this animal, from its habitat in the hair- 
fol 1 icles, acarus folliculorum. 

About six times have I seen, both in the comedones of living per- 

1 The trichomonas vaginalis, with which I atn well acquainted, bears no resemblance 
whatever to the steatozoon folliculorum. The trichomonas is a globular sac, slightly drawn 
out to a point, and having connected with this point a flexible and mobile pedicle, which 
acts the part of a sucker. The sac measures about ^^^ of an inch in diameter. I have 
not seen Donne's figure. 



676 HISTORY AND DESCRIPTION OF THE 

sons, and in the hair-follicles of the dead, a. heart-shaped body, having 
a small process projecting from its broader end. This body was 
somewhat longer than the breadth of the animal, of a brownish color, 
and appeared to be filled with a granular substance. In the hair- 
follicles it was always close to the animalcule, but not connected with 
the latter. This observation, with the fact of the non-resemblance of 
the heart-shaped body to any known human structure, gives strength 
to the conjecture that it must bear some relation to the acarus. It 
might, for example, be an egg-shell, Cfut of which an embryo has 
escaped. 

In reference to the movements of the creature I have been able to 
make the following observations: The palpi are capable of being 
moved in different directions, of being drawn in and stretched out. 
The latter movements are remarked also in the proboscis, which is 
sometimes thrust beyond the palpi, and sometimes drawn back. 
The legs can also be moved in various directions, and the creature is 
often seen to move them backwards and forwards, like a pendulum ; 
they can also be retracted or stretched forth. The thorax and body 
admit of being curved. Although the creature makes all these move- 
ments, it does not walk, but merely changes its position from side to 
side ; once, indeed, I saw an acarus walk a distance equal to his own 
length, but then it was along a hair, which he closely grasped. 

Dr. Simon remarks, that he saw the first and second described 
forms most frequently, and the third and fourth forms, namely, that 
with the short and pointed abdomen, and the slender animal with 
three pairs of legs, only rarely; the former in the proportion of ten 
per cent., the latter six per cent. But he feels so convinced of the 
accuracy of his observation, that he regards as the most positive of 
his data, the presence of six legs only in some. 

After perusing the account of the steatozoon folliculorum, as given 
by its discoverer, Dr. Simon, I determined to proceed to a verification 
of his discoveries, and being provided with an instrument probably 
superior to that employed by Dr. Simon, I have succeeded in making 
out certain points of structure that had escaped his observation. 

I was not long in obtaining subjects; almost every face I met sup- 
plied me with abundance ; and the difficulty seems to be, not to find 
the creature, but to find any individual, with the exception, according 
to Dr. Simon, of newly-born children, in whom these animalcules do 
not exist. It is by no means necessary to commence our search by 
selecting an acne punctata, or even a comedo; almost every collection 
of sebaceous substance which can be squeezed forth from the num- 
berless cutaneous apertures upon the nose, the forehead, the face, and 
probably from other parts of the body, will furnish subjects. More- 
over, Dr. Simon has observed that the parasites are situated near the 
mouth of the follicle; consequently that portion of sebaceous substance 
which is squeezed out with the least force is the part which is most 
likely to be inhabited by the animalcule. 

The steatozoon folliculorum would seem to give rise to no uncom- 
fortable effects by its presence, unless, perchance, it should multiply 
to such an. extent as to become a source of irritation to the follicle, a 



STEATOZOON FOLLICULORUM. 677 

supposition which Dr. Simon admits, for it is found in persons whose 
skin is perfectly healthy and clear, and in whom no signs of cutaneous 
irritation are present. These animalcules undoubtedly feed on the 
sebaceous substance in which they lie imbedded, and which is the 
cause of their existence. I have commmonly found two in the small 
mass of this substance expressed by the fingers, often four and five, 
and in one instance eight, closely held together. Hitherto I have 
confined my examination to living persons, having levied for con- 
tributions among my more intimate friends, and have not as yet had 
recourse to a skin studded with acne. 

In the course of my investigations I have examined several hundreds 
of these animalcules, and have seen all the forms described by Dr. Si- 
mon ; I have also had the good fortune to discover the embryo and the 
ovum. I cannot, however, agree with Dr. Simon with regard to the 
phases of development which he imagines to indicate perfection or 
growth ; on the contrary, I am inclined to believe the most common 
to be the most mature form, and the third or most perfect of Dr. Si- 
mon, an embryonic form. The following are the extremes of measure- 
ment of the perfect animal in fractions of an English inch, according to 
my examinations: 

Entire length. Length of abdomen. Breadth of thorax. 

\\~S 327 555 

B*4 55 5^5 

The animal is divisible into a head, a thorax, and abdomen, the 
whole of thes'e parts being well and distinctly marked. 

The head represents in form, a truncated cone, flattened from above 
downwards, and directed obliquely downwards from the anterior part 
of the trunk. It is composed of two large lateral organs termed by 
Simon maxillary palpi, and of an intermediate triangular organ. 
The maxillary palpi constitute the most considerable portion of the 
head. Each is composed of three segments, and furnished with a 
prehensile extremity, consisting of three curved finger-like organs, 
or claws. The first segment of the maxillary palpus is large and 
long, the two succeeding segments are smaller, and in every respect 
resemble the segments of which the legs are composed. Indeed, 
these maxillary palpi perform the office of arms, the first segment 
being fixed, the next two bending downwards under the first, or 
being stretched directly forwards. It is this flexion and extension of 
a jointed organ that Dr. Simon mistook for extension and retraction. 
On the under part of the first segment of the maxillary palpi I have 
observed a circle, which appears to me to bear some resemblance to an 
eye ; upon this point, however, I am not perfectly satisfied. 

The triangular organ, which includes the mouth of the creature, is 
composed of three elementary parts, namely: 1. Of a triangular pro- 
cess, a prolongation of the membranous case of the animal from the 
neck along the middle line of the upper surface of the head, to the 
extremity of the latter, where it curves downwards, and in the latter 
situation consists of two parallel pieces placed side by side. 2. Of a 
funnel-shaped and tubular organ, or sucker, occupying a central posi- 



678 



HISTORY AND DESCRIPTION OF THE 



tion with regard to all the other cephalic organs. 3. Of another tri- 
angular narrow process, situated on the under part of the head, and 
composed of two lateral pieces. 



Fig. W. 



Fig. X. 



Fig. Y. 




Fig. W. — The steatozoon seen upon its ventral surface. The structure of the head, feet, and plastrum is 
shown, as well as the annulate character of the abdomen. The figure is drawn to a scale of a line to the 
l-2500th of an inch. 

Fig. X.— The steatozoon viewed upon its dorsal aspect. The head is retracted within the thorax. 

Fig. Y. — The steatozoon viewed upon its lateral aspect. The serration of the abdominal segments is 
somewhat exaggerated in all the figures. 

The head is connected to the anterior segment of the thorax by a 
loose membrane, marked on its surface by transverse lines, which 
indicate its susceptibility of being throAvn into folds. This membrane 
is intended to admit of the retraction and extension of the head, and 
by its means the entire head may be drawn in and buried deeply 
beneath the level of the membranous fold here described, so that the 
head is entirely lost to view, and the animal looks decapitated, the 
fold of the cervical membrane forming a perfectly straight border in 
front. This is a peculiarity in the structure of the animal which has 
been passed over by Dr. Simon ; he makes no allusion to any such 
power, and he undoubtedly would have done so had he observed it, 
for the effect of the retraction is too remarkable not to be instantly 
recognized. In fact, when an animalcule is alternately retracting and 
extending its head, the impression to the eye of the observer is that 
of a creature one while furnished with a well-defined head, and the 
next instant decapitated back almost to the level of the anterior seg- 



STEATOZOON FOLLICULORU M. 679 

ment of the thorax. The appearance presented by the animal during 
the retraction of its head is represented in the wood engraving, fig. X. 

The movements of the maxillary palpi are flexion of the last two 
segments, the first segment appearing to be firmly connected with its 
fellow of the opposite side, and being very limited in its movement 
of flexion. The extension of these segments upon the first has led 
Dr. Simon to infer that the palpus might be pushed out, and the sud- 
den disappearance of these two segments by flexion underneath the first, 
has induced him further to believe that they might also be retracted. 
It might be imagined, that when the creature is seen from its under 
surface, this error would become immediately apparent ; but that is 
not the case; for the foreshortening exhibited in the latter view only 
tends to increase the deception. The three finger-like claws at the 
extremity of the palpus are also capable of motion, and grasp upon 
any object within their reach. The triangular pieces, both of the upper 
and lower part of the head, move upwards and downwards on each 
other, and at the same time separate laterally to a slight extent. 

The thorax, which is the broadest and thickest part of the animal, 
and somewhat tun-shaped, is flattened on its under surface. It is com- 
posed of four broad segments, which are joined by a connecting mem- 
brane on the dorsum and sides of the creature, but are continuous 
inferiorly with the broad and strong plastrum which covers the whole 
inferior surface of the thorax. The segments are somewhat convex 
in their antero-posterior diameter, particularly at the upper part, so 
that the outline of the chest in this situation has the appearance of 
being slightly fluted. The anchylosis of the four segments composing 
the plastrum is marked by four transverse markings, consisting each 
of two ridges, which correspond peripherally with the interspaces 
between the legs and centrally bifurcate, one passing forwards to 
unite with the line in front, the other passing back, to become con- 
tinuous with that behind. The same arrangement takes place on the 
opposite side, and a sternal line, consisting of a double crest, is con- 
sequently formed. The ridges of the plastrum here described being 
thicker than the rest of the covering of the animal, are strongly and 
characteristically marked. 

The segmented structure of the thorax permits of a certain degree 
of movement in this part of the creature. 

The legs, which are eight in number, are connected with the sides 
of the plastrum, eaah segment of the thorax sustaining one pair of 
these organs. They are conical in figure, the base of the cone being 
broad, and its apex obtusely truncated, and furnished with three 
finger-like claws. Each leg is composed of three segments, of a proxi- 
mal segment, which is large, and almost triangular in form, the base 
of the triangle (scalene) being directed forwards, and two smaller, 
cylindrical segments, the distal segment supporting the three finger- 
like organs above noted. The legs are all of the same size. 

The movements of the legs are a forward and a backward movement, 
the two small segments forming an acute angle in their bend forwards 
upon the proximal piece, and being extended directly backwards when 
the extension is completed; so that, when the creature advances its 
leg, and places it on a flat surface, the two small segments are directed 



680 HISTORY OF THE STEATOZOON FOLLICULORUM. 

forwards, and, by their under side, rest upon the ground, together 
with the foot, like the long hind-foot of the rabbit ; then, clutching 
upon some object within reach, the segments are carried backwards, 
until they form a straight line with the axis of the proximal piece. 
By this movement, an enormous power of propulsion is gained by the 
creature, and it moves forward with considerable force. Dr. Simon 
remarks, that the animal performs a swimming movement with its 
legs, but without making any advance. That observation may, I 
think, be explained, by its compression, however slight, between two 
plates of glass ; by the injury the animal has received in being pressed 
from the hair-follicle along with the sebaceous substance ; and by the 
fact of the glass upon which it attempts to walk affording no rough 
points to which it can attach itself. The legs are very irregular in 
their movements. 

The abdomen is somewhat variable in point of length, but generally 
more than two or three times longer than the thorax. It is flattened 
on its under surface, and convex above, and tapers gradually from its 
base to its extremity, where it terminates in a rounded point. It is 
composed of a series of extremely narrow annular segments, which 
overlap each other from before backwards. When examined on 
either surface, the margins of these segments present the appearance 
of a regular succession of transverse lines ; and when seen along the 
outline, they give it the character of a serrated edge. The extremity 
of the abdomen is sometimes lengthened out into a small pointed 
process. The aperture of the anus is seen on the under surface of 
the abdomen, near its extremity. 

The annulated structure of the abdomen which is here described, 
permits it to move with considerable freedom, and to curve in any 
direction. 

Of the internal structure, Dr. Simon says nothing more than that the 
abdomen is filled with granular contents, and exhibits several large 
and irregular vesicles, which he compares to oil-globules. The 
granular matter of Simon is cellular tissue in its most simple form ; 
with a good object-glass, the cells are quite distinct, and appear to be 
filled with adipose fluid. These cells are variable in point of size, 
some being exceedingly minute, and others of moderate bulk ; they 
are assembled in such considerable number in the abdomen, as to give 
it a dark appearance, and forming a thin stratum on the inner surface 
of the integument, they obscure the alimentary canal. Sometimes 
the cells are confined to the abdomen, but more frequently they ex- 
tend into the thorax, forming a narrow line, that may be traced 
almost as far as the head. By careful examination, I have succeeded 
in distinguishing the muscular fasciculi which move the legs, and a 
broad oesophagus. In the abdomen I have traced also the outline 
of an alimentary canal, and have seen it terminate by an infundi- 
buliform extremity at the anus. The transparent cell-like organs 
seen in the abdomen of the perfect animal, I regard as dilatations, 
or convolutions of the alimentary canal ; and a dark, brownish mass 
in the commencement of the abdomen I consider to be the liver. 
I have been unable to discover any sexual differences in the numerous 
examples which I have examined. 

\ 



SELECTED FORMULA. 681 



CHAPTER XXV. 

SELECTED FORMULAE. 

SOLUTIO SOLVENTIS MINERALIS; De VaLANGIN; VEL, LlQUOR ACIDI 
ARSENIOSI HYDROCHLORICI. 

R. — Acidi arseniosi, gr. xxx. 

Acidi hydrochlorici, gr. xc. 

Aqua? destillatse, l xx - 

Dissolve the arsenious acid in the hydrochloric acid diluted with one ounce of the 
distilled water ; then add the rest of the water. This solution contains one grain 
in a little more than five drachms, consequently is somewhat less than half the 
strength of Fowler's solution, which contains one grain in two drachms. 

MlSTURA ACIDI ARSENIOSI HYDROCHLORICI. 

R. — Solut. solventis mineralis, De Valangin, . . . gij. Qij. 

Acidi hydrochlorici diluti, 3J- 9J- 

Syrupi simplicis, . ....... ^iss. 

A drachm to be taken in an ounce of water, with meals, three times a day. 

MlSTURA HYDRIODATIS HYDRARGYRI ET ARSENICI. 

R. — Liq. hydriodatis hydrargyri et arsenici, Donovani, . j|ss. 
Syrupi simplicis, ........ ,^iss. 

M. 

A drachm to he taken in an ounce of water, with meals, three times a day. 

MlSTURA EERRO-ARSENICALIS, INFANTIBUS. 

R. — Vini ferri, 

Syrupi simplicis, aa ^ss. 

Liquoris potassie arsenitis, rcjj xxxij. 

Aqua? anethi, ^j. 

M. 
A drachm to he taken, with meals, twice or three times a day. Each drachm con- 
tains two minims, and may be increased to three or four minims if found desirable. 

MlSTURA FERRO-ARSENICALIS. 

R. — Vini ferri, ^iss. 

Syrupi simplicis, 

Liquoris potassa; arsenitis, aa # ^ij. 

Aquae destillatae, ^ij. 

M. 
The dose of one drachm contains somewhat less than four minims, and may be 
administered three times a day ; either with or directly after meals. 



MlSTURA OLEI MORRIIUiE CUM ARSENICO. 



R. — Olei morrhuse, 

Vitelli ovi, 

Liquoris potassaj arsenitis, 

Syrupi simplicia, . 

Aquae destillataa, 
M. 



no. j. 

ttjj lxiv. 

^ij. 

q. s. ad. %iv. 



A drachm to be taken with, or directly after meals, three times a day; for infants. 



082 SELECTED FORMULAE. 

PULVIS SOD^! ARSENIATIS. 

R. — Sodae arseniatis, g r -j- 

Sacchari albi, gr. xlviij. 

Misce bene, ut fiat pulvis ; et divide in chartulas xxiv. 
One to be taken three times a day with meals ; the powder to be placed on the 
tongue ; for infants. The dose for adults should be T ^ or i of a grain. 

Pilule sod^e arseniatis, composite. 

R. — Sodae arseniatis, gr. ij. 

Solve in aqua destillata, q. s. 

Pulveris antimonii oxysulphureti, . . . . gr. xxiv. 

Pulveris guaiaci, gr. xlviij. 

Mueilaginis acaciae, q. s. 
Misce bene, et divide in pilulas xxiv. 

One to be taken, with meals, three times a day. 

Pilule arsenici, quince, et ferri. 

R. — Sodae arseniatis, gr. ij . 

Quinae disulphatis, gr. xij. 

Ferri sulphatis, gr. vj. 

Extracti anthemidis, 3J. 

Misce bene, et divide in pilulas xxiv. 
One to be taken, with meals, three times a day. 

PlLULiE QUINCE ARSENITIS, COMPOSITE. 

R. — Quinae arsenitis, gr. x. 

Antimonii oxysulphureti, 9J. 

Pulveris guaiaci, 3J. 

Mueilaginis acaciae, q. s. 
Misce bene, et divide in pilulas xxiv. 

One to be taken, with meals, three times a day. 

Pilule Asiatics. 

R. — Arsenici protoxydi, gr.lv. 

Piperis nigri, Six. 

Asclepiadis gigantea? radicis corticis, .... 31V. ^iv. 
Misce bene, ut fiat pilulas 800. 
For mode of preparation and exhibition of these pills, see page 367. 

Unguentum oxydi zinci, benzoatum. 

Bell's Formula. 

R. — Adipis preparatas, j|vj. 

Gurnmi Benzoini pulveris, jjj. 

Liquefac, cum leni calore, per horas viginti quatuor, in vaso clauso ; dein 
cola per linteum, et adde, 

Oxydi zinci, purificati, §j. 

Misce bene, et per linteum exprime. 

Unguentum oxydi zinci benzoatum cum spiritu vini. 

R. — Unguenti oxydi zinci, benzoati, gij. 

Spiritus vini rectificati, gij. 

Misce, ut fiat unguentum. 

Instead of spirits of wine, spirits of camphor, distilled glycerine, liquor plumbi 
diacetatis, Peruvian balsam, or the juniper tar ointment, may be combined with 
the benzoated ointment of oxide of zinc, in the same proportion as above, one 
drachm to the ounce. 



SELECTED FORMULA 688 

Unguentum picis juniperi. 

R. — Olei juniperi pyrolignici, 1 §j. 

Sevi ovilli purificati, ....... gvj. 

Adipis purificatte, ........ gij. 

Liquefac cum leni calore et agita bene ut fiat unguentum. 

This ointment may be used of the above strength, or diluted in any suitable de- 
gree. 

Unguentum sulphuris hypochloridi, compositum. 

R. — Sulphuris hypochloridi, ^ij. 

Potassas subcarbonatis, gr. x. 

Adipis purificata?, gj. 

Olei amygdalae essentialis, ttjjx. 

Misce bene, ut fiat unguentum. 

Unguentum sulphuris et picis. 

For ringivorm, Wilkinson. 
R. — Sulphuris sublimati, 

Picis liquidae, 

Adipis purificatas, ....... aa^ij. 

Cretaa preparatae, gj. 

Ammoniaa hydrosulphureti, gss. 

Misce, ut fiat unguentum. 

Unguentum sulphuris cum oleo laurino. 

For ringworm, Dr. Walter Dick. 

R. — Olei laurini, 5iss. 

Sulphuris vivi, gss. 

Pulveris camphorae, gr. x. 

Misce bene, ut fiat unguentum. i 

Unguentum stimulans. 

R. — Pulveris cantbaridis, sjvj. 

Adipis purificatas, ^iij. 

Macera, cum leni calore, per horas viginti quatuor, et, per chartam bibulam, 

cola. 

This ointment is too strong for use in its present state, and when required as a 

stimulating remedy should be reduced by means of any agreeable pomatum [adeps 

odorata], in the proportion of one part of unguentum stimulans to four or eight of 

the diluting medium. 

Unguentum trichogenosum. 

R. — Unguenti stimulantis, 

Butyri cacaonis theobromatis, .... aagij- 

Butyri jasminae, ........ sss. 

Adipis odorata?, Jj. 

Misce bene, ut fiat unguentum. 
To be well rubbed among the roots of the hair, daily, after thorough brushing. 

Unguentum trichogenosum, Dupuytren. 



• 33; 

• S3- 

aa 11}? xv. 



R. — Purified beef marrow, . 

Acetate of lead, .... 

Peruvian balsam, .... 

Tincture of cantharidcs, 

Essential oil of cloves and canella, 
M isee I, in.', ill liat uiigwiituiu. 

Ungukntim thh'iiogenosum, Gibert. 

R. — Purified beef marrow, Jjvj. 

Oil of sweet almondb, grj. 

Powder of cinchona bark, 3j. 

Misce bene, u( liat unguentum. 

* The Huile do Cade is an impure oleum juniperi pyrolignicium. 



684 SELECTED FORMULA 



LOTIO CAPILLARIA STIMULANS. 



R. — Olei amygdala? clulcis, . 

Liquoris ammonias fortius, 

Spiritus rosmarini, 

Aqua? mellis, 
Misce, iiat lotio. 



LOTIO CAPILLARIA REFRIGERANS 



R. — Olei amygdala? dulcis, 
Soda? biboratis, 
Aqua? florium aurantii, 
Aqua? destillata?, . 

Misce, fiat lotio. 



LOTIO HYDRARGYRI BICHLORIDI, EX EiMULSIONE AMYGDALARUI 

R. — Amygdalarum amarum, no. xx. 

Aqua? destillata?, 3 v j- 

Contunde et tere simul dein cola et adde, 

Hydrargyri bichloridi, ....... gr. xvj. 

Spiritus vini rectificati, gij. 

Misce, ut fiat lotio. 

TlNCTURA CROTONIS TIGLII. 

R. — Seminum contusorum, 2j. 



o 1 



Spiritus vini rectificati, 
Macera per dies quatuordecim et cola. 
A valuable cutaneous stimulant. 

SOLUTIO ^ETHERIALIS IODINII ET MASTICHES. 

Dr. T/iomas Smith Rowe. 

R. — Spiritus vini rectificati, gv. 

xEtheris sulphurici, ^iij. 

Misce; et adjice, 

Gummi majtmbes, gr. xxv. 

Solve et cola, dein adde, 

Iodinii, Qij. 

Fiat solutio. 

This solution will be found to be a valuable application for scrofulous tubercles 
and eruptions, and for the tubercular forms of lupus and elephantiasis. The 
mastich forms a varnish-like film on the skin, which detains the iodine, and facili- 
tates its absorption. 

Adeps benzoata. 

R. — Adipis purificata?, ^vj. 

Gummi benzoini, pulveris, . . . : . . 5jj. 
Tere simul, dein liquefac cum leni calore, per horas viginti quatuor, in vaso 

clauso, et cola per linteum. 

This ointment, which, with the addition of oxide of zinc, is the benzoated zinc 
ointment, may be used alone, or combined with other substances; or, it maybe used 
with advantage to dilute other ointments, tending to preserve them from rancidity, 
as well as communicating an agreeable odor. 

Note. — Since the above formula? were in print, my attention has been called to 
the liquor arseniei chloridi of the London Pharmacopoeia ; which corresponds with 
the liquor acidi arseniosi hydrochlorici, de Valangin, and may be taken as a proper 
substitute for it, but is somewhat stronger, containing about (somewhat less) one 
grain of arsenious acid in four drachms. The liquor arseniei chloridi is consequently 
less than half the strength of the liquor potassaa arsenitis, which contains two grains 
and a half in four drachms. Therefore, taking the standard dose of the latter at 
five minims, the dose of the liquor arseniei chloridi should be ten minims. 



INDEX. 



Abinzoae, on the acarus scabiei 
Absorbent property of skin 
Acarus autumnalis, 

folliculorum, 

scabiei, . 

Stockholmii, 
Achroma, 
Acne, 

indurata, ■ 

punctata, 

rosacea, . 

simplex, . 

vulgaris, 
Acret, Mr., case of melanopathia, 
Adams, Dr., on the acarus scabiei, 
" on scabies in Madeira 

Addison, on melanopathia. 
iEstus volaticus, 
Affusion, 
Agnails, 
Agria, . 
Albinismus, . 
Albinoes, 
Aldrovandus, on the acarus scabiei 
Alley, Dr., on hydrargyria, 
Alopecia, 

accidentalis, . 

areata, . 

circumscripta, 

congenita, 

porriginosa, . 

senilis, . 

syphilitica, 

unguealis, 
Alphos, .... 
Alphosis, 

ajthiopica, 
Ambustio, 

erythematosa, 

gangrenosa, . 

vesicularis, 
Anaesthesia, . 
Angina scarlatinosa, 
Aiiidrosis, 
Anthrax, 

Area, .... 
Arrectores pilorum, 
Arsenic, its therapeutic effects 
Arsenical preparations. 
Arteries of the skin, 
Asclepias gigantea, 



PAGE 

659 
73 

277 

677 
3, 659 
. 275 

535 
, 594 
, 595 
, 594 
, 595 
, 594 

594 
, 528 
. 664 
. 265 
. 129 
. 175 
, 455 
, 653 
. 170 
. 535 
. 535 
. 660 
. 186 
. 605 



. 535 

. 536 

. 285 

. 286 

. 287 

. 287 

. 513 

. 443 

. MS 

243, 247 

. 606 

. 35 

. 108 

. 110 

. 36 



Asiatic pills,-. 
Atheroma, 
Athrix calvities, 

simplex, 
Atonic ulcers, 
Axile corpuscles, 



PAGE 

367, 682 
. 591 
. 607 
. 604 
. 402 
. 36 



Bacchia, 

Baker, on the acarus scabiei, 

Baker's itch,. 

Baldness, 

Barbadoes leg, 

Barbadoes tar, 

Basement membrane, 

Beau, Dr., growth of nails, 

Becquerel and Breschet, animal heat, 

Bichfit, abnormal situation of hair, 

Black measles, 

Blactise, vide rubeola, . 

Blanching of the hair, . 

Bloody sweat, 

Boil, .... 

Bonanni, on the acarus scabiei 

Bonomo, on the acarus scabiei, 

Borellus, on the acarus scabiei 

Bricklayer's itch, . 

Briquet, M., treatment of variola, 

Bryce, Dr., vaccination test, 

Bucnomia tropica, 

Bulla?, .... 

Bullous eruptions, 

Burns, .... 

Burnt holes, . 



Cacochymia, . 

Calcareous miliary tubercles. 

Callosities, 

Callus, .... 

Calvities, 

Cancrois, 

Canities, 

Capillaries of the derma, 

Carbuncle, 

Carcinoma glandulaa sebiparre 

Casal, on the acarus scabiei, 

Oaastios, 

Ceeley, Mr., on vaccination 

Cerumen, 

Chalazion, 

Chapped nipples, . 

Chaps, treatment of, 



595 
663 
171 
605 
335 
109 
48 
70 
80 
602 
436 
432 
612 
551 
245 
662 
661 
662 
204 
475 
499 
335 
223 
223 
285 
239 



590 
521 
521 
607 
324 



. 37 

243, 247 

. 597 



320 
75 
53 
591 
128 
128 



686 



INDEX. 



Chelois, 

Chicken-pox, . 

Chiggre, 

Chilblain, 

Chloasma, 

Chromatogenous disorders, 

Chromidrosis, 

Cimex lectuarius, . 

Cinguluni, 

Classification of skin diseases, 

Clavus, .... 

Cnidosis, 

Cod-liver oil,. 

Cold affusion, 

Comedones, . 

Commission of Vaccine, report, 

Contagion, nature of, . 

Contractility of the skin, 

Copper-color, definition of, 

Corium,. 

Corns, .... 

fibrous, . 

laminated, 

soft, 
Cornua humana, . 
Corpus papillare, vide papillary layer, 
Corpusculum tactus, 
Couperose, 
Cow-pox, 
Crab-louse, . 
Crusta lactea, 
Cryptogamia in favus, . 

in sycosis, 
Cuticle, anatomy of, 
Cutis, anatomy of, 
Cutis anserina, 
Cutis unctuosa, 
Cysts, serous, 



PAGE 

324 
482 
281 
295 
538 
611 
550 
281 
228 

82 
, 522 
153 
114 
455 
571 
502 
431 

34 
390 

33 
521 
522 
521 
523 
584 

35 

36 
595 
484 
279 
, 216 
644 
635 
3, 39 

33 

35 
555 
591 



Dandruff, 
Dartre, . 

crustacee, 

crustacee 

crustacee stalactiforme, 

de la graisse, . 

erysipelateuse, 

erythemoide, . 

furfuracee, 

rougeante, 

squameuse, 

squameuse humide, 
Decoloratio argentea, 
Defoedatio unguium, 
Defluvium capillorum, 
De Geer, on the acarus scabiei, 
Degeneratio unguium, 
Depilatories, . 
Derma, anatomy of, 
Diapompholigos, 
Diet, in diseases of the skin, . 
Dobson, Sir Richard, erysipelas, 
Donovan's solution, 
Dupuytren's pomade for the hair, 
Dyschroma, .... 



Ear-wax, 
Eating hive, . 
Ecchymoses, . 
spontanea:, 



124, 125 
. 224 
. 212 
. 213 
. 214 
. 324 
. 185 
. 117 

300, 304 
. 319 
. 300 

184, 200 
. 541 
. 655 
. 604 
. 669 
. 655 
. 604 
33, 34 
. 294 
. 102 
. 141 
. 313 



of variola 



Ecphlysis eczema, 

herpes, 

pemphigus, 

pompholyx, 

rhypia, . 
Ecphyma, 
Ecpyesis ecthyma, 

impetigo, 

scabies, . 
Ecthyma, 

acutum, . 

cachecticum, 

chronicum, 

infantile, 

luridum, 

syphiliticum, 

vulgare, . 
Ectrotic treatment 
Eczema, 

articulorua 

aurium, . 

capitis, . 

chronicum, 

digitorum, 

faciei, 

furfuraceum, v\ 

impetiginodes, 

infantile, 

madidans, vid, 

mamillarum, 

manuum, 

mercuriale, 

papulosum, vide lichen. 

pedum, 

pudendi, 

rubrum, 

simplex, 

solare, 

squamosum, vide pityriasis. 

vesiculosum, vide simplex. 
Eczematous eruptions, 
Elephanta, 
Elephantiasis, 

alopecia, 

anaesthetica, 

Arabum,. 

cases of, . 

existing forms 

Graecorum, 

legitima,. 

leonina, . 



ide pityriasis. 



rubrum. 



of, 



Orientalis, 

pathology, 

treatment of, 

tuberculosa, 
Emphlysis erysipelu 

miliaria, 

pemphigus, 

vaccinia, 

varicella, 
Emphyma encystis, 
Enanthesis, . 
Encysted sebaceous tumors, 
Endermic medicines, 
Ephelis, 

alba, 

hepatica, 

ignealis, . 

lentigo, . 









INDEX. 


687 


PAGE 




PASE 


Ephelis scorbutica, .... 540 


Fabricius, on the acarus scabiei, 


. 669 


umbrosa, . 




. 537 


False measles, 


144, 145 


Ephidrosis, . 




. 542 


Favus, 


. 637 


" cruenta, . 




. 551 


confertus, 


. 637 


discolor, . . , 




. 550 


dispersus, . 


. 637 


olens, 




. 548 


Febris erysipelatosa, 


. 132 


partialis, 




. 543 


morbillosa, . 


. 436 


profusa, . 




. 542 


scarlatinosa, . 


. 441 


Epichrosis, . 




. 525 


Felting of the hair, 


. 611 


alphosis, 




. 535 


F.icus unguium, 


. 654 


ephelis, . 




. 537 


Fiery spots, ..... 


. 123 


lenticula, 




. 538 


Filaria medinensis, 


. 282 


poecilia, . 




. 536 


Fish-skin disease, . 


556, 563 


spilus, .... 




534, 601 


Flores unguium, . 


. 655 


Epidermis, anatomy of, 




33, 39 


Follicular elevations, 


. 590 


Epinyetis, 




. 244 


tumors, . . . . . 


. 591 


Erectile tumors, . 






510 


Fourcault, M., his experiments, 


. 79 


Eruptive fevers, . 






428 


Freckles, .... 


. 538 


Erysipelas, 






131 


Frostbite, .... 


. 295 


bullosum, 






134 


Furuncular eruptions, . 


. 243 


capitis, . 






135 


Furunculus, { 


6, 243, 245 


erraticum, 






134 


anthracoides, . 


. 249 


faciei, 






135 






gangrenosum, . 






137 


Gabueinus, on the acarus scabiei, 


. 660 


mammae, 






135 


Gale, 


. 263 


metastaticum, 






134 


Gales, M., on the acarus scabiei, 


. 665 


miliare, . 






134 


Gelatio, .... 


. 295 


neonatorum, . 






136 


Glycerine, .... 


. 115 


cedematodes, . 






134 


Goose-skin, .... 


. 35 


phlegmonodes, 






136 


Gown, red, .... 


. 174 


phlyctenodes, . 






134 


Grando, .... 


. 591 


simplex, 






132 


Grantham, Mr., on erysipelas, 


. 140 


umbilicale, 






136 


Gras, Albin, experiments, 


268, 273 


vesiculare, 






134 


Grayness of the hair, . 


. 612 


Erythema, 




9 


3, 116 


Gregory, Dr., on petechial cow-po: 


i, . 497 


centrifugum, . 






316 


Grocer's itch, 


. 171, 204 


chronicum, 






123 


Grubs, 


. 571 


circinatum, 






118 


Gruby, Dr., on mycodermis, . 


. 620 


erysipelatosum, 






131 


researches on sycosis, 


. 635 


folliculorum, . 






630 


Grutum, .... 


. 590 


fugax, 






118 


Gryllus verrucivorus, 


. 520 


gangrenosum, . 






137 


Gum-rash, .... 


174, 176 


ichorosum, 




18 


6, 200 


Gutta rosacea, 


. 595 


intertrigo, 






121 






iris, 






230 


Hasmidrosis, .... 


. 551 


lseve, 






119 


Hasmorrhagic measles, . 


. 437 


marginatum, . 




11 


d, 165 


Haemorrhoea petechialis, 


. 339 


mercuriale, 






186 


Haflenreffer, on the acarus scabiei 


. 661 


nodosum, 






122 


Hair, abnormal direction, 


. 611 


cedematosum, . 




11 


i, 134 


alteration of color, . 


. 611 


palmare syphiliticum, 






405 


anatomy, 


. 54 


papulatum, 






122 


augmented formation, 


. 600 


paratrimma, . 






121 


chemical composition, 


. 67 


pityriasis, 






124 


color 


. "59 


plantare syphiliticum, 






405 


development, . 


66 


syphiliticum, . 






412 


diminished formation, 


. 604 


tuberosum, 






122 


diseases, 


. 599 


vesiculare, 






186 


downy, .... 


57, 67 


volaticum, 






175 


felting of the, 


. 611 


Essera, .... 




. 15 


3, 168 


growth of the, 


. 61 


Ebthiomene serpigineuse, 






. 319 


number, 


. 65 


Etmuller, on the acarus scab 


ei, 




661 


Hair-follicles, anatomy, 


. 60 


Bxanthema labiale, 






226 


diseases, 


. 629 


Oxanthemata, 






428 


inflammation, . 


. 630, 633 


Exanthema, . 






144 


Hall, Marshall, on njovi, 


. 512 


Exormia lichen, 






163 


Harvest bug, 


. 277 


milium, . 






590 


llauptmann, on the acarus scabiei 


. 661 


prurigo, . 






177 


Hebra, burns, treatment of, . 


. 294 


strophulus, 






174 


perpetual warm bath, 
small-pox, treatment of, 


. 294 
. 473 



688 



INDEX. 



Helmintiasis, 
Henderson, Dr., on mo] 
Hepatizon, 
Hereditary syphilis, 
Herpes, 

anricularis, 

circinatus, 

esthionienes, . 

exedens, 

furfuraceus circina; 

iris, 

labialis, . 

miliaris, . 

nasalis, . 

palpebralis, 

phlyctenodes, . 

praeputialis, . 

proserpens, 

pudendalis, 

squamosus, 

squamosus malidans, 

tonsurans, 

zoster, - 
Herpetic eruptions, 
Higginbottom, Mr., on 
Hirsuties, 
Hives, . 

eating, . 
Hordeolum, . 
Horn-pox, 
Horns, human, 
Huile de Cade, 
Humid tetter, 
Hydrargyria, 

febrilis, . 

maligna, 

mitis, 
Hydroa, 

febrile, . 
Hydrocotyle asiatica, 
Hyperesthesia, 
Hyperidrosis, 
Hypertrophia venarum, 

Iatraleptic medicines, 
Ichthyosis, . 

congenita, 

cornea, . 

furfuracea, 

mollis, 

nitida, . 

reticulata, 

sebacea, 

serpentina, 

simplex, . 

spinosa, . 

spuria, . 

squamosa, 

vera, 

vulgaris, . 
Idrosis, 

maligna, . 

partialis, 

simplex, . 
Ignis persicus, 

sacer, 

Sancti Anthonii, 
Impetiginous eruptions 
Impetigo, 

capitis, . 



erysipelas 



239, 
244, 



109. 



282 
582 
538 
411 
224 
227 
230 
319 
319 
305 
230 
226 
225 
227 
227 
225 
227 
228 
227 
300 
185 
617 
228 
223 
141 
600 
480 
239 
247 
482 
584 
683 
184 
186 
187 
187 
186 
208 
226 
367 
513 
542 
508 

74 
556 
556 
569 
556 
556 
556 
556 
563 
556 
556 
568 
563 
564 
556 
556 
542 
554 
543 
543 
247 
228 
131 
210 
212 
216 



Impetigo erysipelatodes. 

erythematica, 

faciei, 

figurata, . 

lactantium, 

scabida, . 

sparsa, . 
Infection, nature of, 
Inflammatio folliculorum, 
Ingrassias, on the acarus scabiei, 
Insensible perspiration, . 
Inunction in erysipelas, . 
Iodide of arsenic in lepra, 
Ionthus, 

Iron in erysipelas, . 
Itch, .... 

baker's, . 

bricklayer's, .... 171 

grocer's, .... 171. 

washerwoman's, 
Itch-animalcule, . 



Jackson, Mr., case of melanopathia, 
Jacobovics, Dr., on molluscum, 
Jobertus, on the acarus scabiei, 
Johnson, Dr. J., on lichen tropicus 
Joint evil, .... 



Kelis, 

clavata, . 

cylindracea, 

genuina, . 

oralis, 

radiciformis, . 

spuria, . 

treatment of, . 

vera, 
Keloides, vide Kelis, 
Kelois, vide Kelis, 
Kerion. 
Kheesah, 
Kibe, . 



Land-scurvy, . 

Lanugo, 

Latreille, on the acarus scabiei, 

Legrand, M., treatment of variola. 

Lentigo, 

Leontia, 

Leontiasis, . 

Lepidosis lepriasis, 

pityriasis, 
Lepra, . 

alopecia medii aevi 

alphoides, 

Arabum, 

anaisthetos, 

articulationum, 

capitis, . 

circinata, 

diffusa, . 

elephantia, 

Graecorum, 

guttata, 

inveterata, 

leontina, 

leuce, 

medii sevi, 

mercurialis, 

mortificans, 



334, 



304, 



AGE 

215 
215 
216 
213 
216 
215 
215 
431 



76 
141 
312 
594 
139 
263 
171 
204 
204 
171 
267 

527 

581 



324 
324 
324 
324 
324 
324 
331 
331 
324 
324 
324 
637 
560 
295 

255 

r, 67 

670 
473 
538 
334 
338 
300 
124 
300 
340 
304 
333 
340 
340 
308 
305 
306 
336 
336 
304 
307 
336 
337 
336 



689 



Lepra, nigricans, . 

nodosa, . 

phlegmatica, . 

rheutnatica, . 

syphilitica, 

taurica, . 

treatment of, . 

tuberculosa, . " 

unguium, . ' 

vulgaris, 
Leprosy of the Arabian 

Crusaders, 

Jews, 

Middle Ages, . 
Leuce, . 

vulgaris, 
Leucopathia, 
Leuccethiopes, 
Levitican code, 
Lichen, . 

agrius, . 

annulatus, 

circumscriptus, 

confertus, 

corymbosus, . 

disseminatus, . 

eczematosus, . 

gyratus, . 

ichorosus, 

lividus, . 

marginatus, 

pilaris, . 

pustulosus, 

serpiginosus, . 

simplex, . 

syphiliticus, 

tropicus, 

urticatus, 
Lichenous eruption, 
Lichenstein, Dr., on ino 
[rinee of motion, . 
Linnasus, on the acarus 
Linuor hydriodatis ars< 

eyn. • 

Lis ton, treatment of erj 
Lotions, in cutaneous '1 
Lunula, 

Lupiform syphilis. 
Lupus, . 

erythematosus, 

exedens, 

uo 11 exedens, . 

syphiliticus, . 

treatment of, . 

uloerosus syphilitic 

vorax, 

Lymphatic plexus of th 

Maculic, 

fusoes, 

hepaticse, 

nigrse, 

BypbiliticaB, . 
Mahon, MM., breatmen 
Mai de in < Ihersonese, 
Bd Hi de la 1 Irimee, . 
Mai-assimilation, . 
Malignant tubercle, 
Mali.-- aoari, . 

cimicis, . 


culat 

scab 

nici 

f.sipel 
sease 

is, 
e den 

of f 


3C 

on. 

et h; 

is, 

IV us, 


PAGE 

. 307 
. 336 
. 340 
. 340 
. 307 
. 335 
. 310 
. 336 
. 30S 
. 305 
. 333 
. 333 
. 333 

4, 317, 337 
. 340 
. 535 
. 536 
. 377 
94, 163 
. 170 
. 165 
. 166 
. 388 
. 388 
. 388 
. 170 
. 165 
. 170 
. 164 
. 165 
. 165 
. 388 
. 165 
. 164 
. 388 
. 168 
. 107 
. 161 
. 507 
. 47 
. 667 

drar- 

. 313 
. 140 
. 1 03 
. 69 
. 4(19 
. :; 1 5 
316, -n» 7 
. 319 

. 1 1 :: 
. 320 
. 109 
. 319 
. 37 

. 525 

. 63 7 

. 538 
. 255 
. 387 
. 652 
. 334 
. 331 
. 99 
. 597 
. 274 



Malis filarite, 

pediculi, 

pulicis, . 
Mandl, researches on th 
Measles, 

Meibomian glands, 
Melanopathia, 

. syphilitica, 
Melanosis, cells of, 
Melasma, 
Meliceris, 
Melitagra, 
Mendacia ungwium, 
Mentagra, 
Mentagrophyte, 
Mercurial eczema,. 
Midivaine, Dr., treatme 
Milia, . 
Miliaria, 

alba, 

rubra, 
Miliary eruption, . 

vesicles, . 
Milium, 
Moles, . 
Molluscum contagiosum 

parvum, . 

pisiforme, 

sessile, 

simplex, . 

subglobulosum, 
Morbilli, 

benigni, . 

confluentes, 

erethrici, 
Morbus heraeleiiS; 

herculeus, 

maculosus, 

pedicularis, 

pilaris, . 

pulicarus, 
Morphoea, 

alba ansesthetica, 

atrophic;), 

lardacea, 

tuberosa, 

alopeciata, 



Morpiones, 
Mother's murks, 

Moufet, on the acarus .- 
Mower's mite, 
Mmlar or M miliar, 
Miiller, on the acarus Si 
Muscular fibre of skin, 



N:c\ i materni, 
pigmentosi, 
pilosi, 
vasoulosi, 

Nsevus, . 

a raneUS, . 

arteriosus, 
flammeus, 
maternus, 
pigmentosus, 
treatment of, 
venosus, . 

Nail-lolliclcs. 
Nails, anatomy, 



PAGE 

2S2 
277 
280 

62 
433 

53 
526 



iola, 



45 
540 
591 

212 

655 

634 

635 

ISfi 

474 

591 

208, 543 

208, 543 

208, 543 

. 208 

. 208 



534, 601 

. 573 

. 573 

. 573 

. 573 

. 573 

. 573 

. 433 

. 433 

. 441 

. 433 

. 334 

. 334 

. 255 

. 277 

. 632 

. 255 

. 369 

. 372 

. 372 

. 309 



. 375 

. 375 

. 279 

534, inn 

. 660 

. 277 

. 366 

. 670 

. 34 



. 601 

. 534 

. 001 

. 510 

. 51(1 

. 510 

. 5 11 

. 510 

510, 601 

. 534 

. 511 

. 510 

. 68 

. 08 



690 



IX HEX. 





PAGE 




Nails, chemical composition, . 


71 


Petechias, . . . . . 


diseases. . 


653 


after vaccination, . 


Narcosis folliculorum, . . . . 


632 


Petechial scurvy, . . . . 


Nerves of the derma, . 


37 


Phacia 


Nettlerash, ...... 


153 


Phsenicismus, . . . . 


Nigredo cutis, 


52(5 


Phaenigmus petechialis, 


Nigrities, ...... 


526 


Phlyctenule, . . . . 


Nirles, 


225 


Phlyzacia, . 


Nitrate of silver in erysipelas, 


141 


Phthiriasis 


Noli me tangere, . . . . . 


319 


Phyma, ...... 


Nosophyta 


636 


anthrax, . . . . 
furuneulus, . 


Ointments in cutaneous diseases, . 


104 


hordeolum, . . . . 


Oliffe, Sir J., treatment of variola, 
Olophlyctis. ...... 

labialis, 

miliaris, ..... 
Onychia, 

maligna, .... 

serofalosa, .... 


475 
224 
226 
225 
656 
657 
322 


sycosis, . 
Physiology of the skin, 
Phyto-alopecia, . . . . 
Picton, Dr., treatment of variola, 
Pigment, chemistry of, . 

cells, 

Pigmental - } diseases, 


syphilitica, .... 
Ophiasis, 37 


403 

i, 606 


naevi, . 
Pilous naevi, . 
Pimply diseases, . . . . 


Oribata geniculata, 


675 


Osmidrosis, ..... 


548 


Pityriasis 


Oxide of silver stain, 


541 


capitjs, . . . . . 

decalvans, . 
labioruui, . 


Pachulosis, 


525 


nigra, . . . . . 


Pacinian corpuscles, 


38 


oris, 


Panaris, 


658 


pal maris, . . . . 


Papillae of the derma, . 


35 


palpebrarum, . . . . 


Papillary layer of the derma, 


35 


plantaris, . 


Papulae, Willan's first order, 


161 


prseputialis, . 


Papulae epiderniicae, 


554 


pudendalis, . . . . 


Papulous eruptions, 


161 


rubra, 


Parker, Langston, on syphilis, 


419 


versicolor, . 


Paterson, Dr., cases of molluscum, 


583 


vulgaris, . . . . 


Pathology of the skin, . 


91 


Plica poloniea, . . . . 


Pearly tubercles, .... 


590 


caudiformis, . 


Pediculus capitis, .... 


27S 


multiformis, . 


corporis, .... 


278 


Plunibe, treatment of favus, . 


ferox, ..... 


279 


Pompholyx 


pubis, 


279 


benignus, . 


Pemphigus, 


235 


diutinus, . 


aoutus 


235 


solitarius, . 


apyreticus, .... 


235 


Porcupine disease, 


ehronicus, .... 


238 


Pores of the sudoriferous ducts, . 


confertus, .... 


235 


Porphyra, 


confluens, .... 


235 


hemorrhagica, 


eongenitus, .... 


235 


nautica, . 


contagiosns, .... 


240 


simplex, . 


gangrenosus, .... 


239 


Porrigo asbestina, . . . . 


indicus, 


240 


circinata, . 


infantilis, .... 


239 


decalvans, . 


iris, 


230 


favosa, . 


pyreticus 


235 


furfurans, . . . . 


simultaneus, .... 


235 


granulata, . 


solitarius. .... 


23S 


larvalis, 


successivus 


235 


lupinosa, . 


vulgaris, .... 


235 


scutulata, . 


Pemphix 


235 


tonsoria, . 


Pereira, Dr., case of melanopathia, 


528 


Porrigophyta, . . . . 


Pernio, ..*.... 


295 


Prickly heat 


Perspiration, .... 


51, 76 


Johnson's observations, . 


chemical composition of, 


80 


Win! i-i bottom's. 


colored 


550 


Prima, 


disorders of, . 


542 


Prurigo, 


morbid< 


8J 


formieans, . 


Perspiratory glands, 


49 


mitis 


tubes 


50 


podicis, 





INDEX. 


691 




PAGE 




PAGE 


Prurigo, pudendalis, 


. 179 


Roseola, orbicularis, 


. 387 


scroti, . . . . 


. 179 


papulata, . 


. 387 


senilis, 


. 179 


punctata, . 


147, 387 


Pruritus 


177, 514 


rheumatica, . . . . 


. 150 


ani, 


. 515 


syphilitica. . 


. 386 


general, . ' . 


. 514 


vaccina, . 


. 149 


praeputii. . 


. 515 


variolosa, . 


. 149 


pudendi, . . . . 


. 516 


versicolor, . 


. 387 


scroti, ..... 


. 515 


Rose-rash, 


. 144 


treatment of, ... 


. 516 


Rougeole, . 


. 432 


urethrse, . . . . 


. 515 ! 


Rubeola, . . . . . 


. 432 


Psora, vide scabies, 


. 263 


maligna, vide rubeola nigra, . 


. 436 


Psoriasis, . . . 94, 9 


5, 183, 199 


nigra, 


. 436 


confluens, . . . . 


. 306 


rosalia, 


. 432 


diffusa, 


. 306 


sine catarrho, 


. 436 


discreta, 


. 304 


sine exanthemate, . 


. 436 


guttata, . 


. 304 


vulgaris, . 


. 433 


gyi-ata, 


. 40S 


Rumex gigantea, . 


. 366 


infantilis, . . . . 


. 189 


Rupia, 


. 399 


inveterata, 


. 307 


escharotica, . 


. 239 


labialis, 


. 124 


prominens, . 


. 400 


palmaris, . 


. 405 


simplex, . 


. 400 


palpebrarum, . 


. 124 


syphilitica, . . " . 


. 399 


plantaris, . 


. 405 






prasputialis, . . . . 


. 124 


Saracenia purpurea, 


. 471 


scrotalis, . 


. 124 


Satyria, . . 


334, 339 


Psoriasis syphilitica, 


. 412 


Satyriasis, . . . 


334, 339 


vulgaris, . 


. 306 


Satyriasmos, . . . . . 


334, 339 


Psydracia, . . . . . 


. 212 


Sauriderma, .... 


. 563 


Pterygium unguis, 


. 653 


spinosum, 


. 568 


Pulex irritans, 


. 280 


squamosum, . 


. 564 


penetrans, 


. 280 


Scabies, .... 


. 263 


Puncture in erysipelas, 


. 141 


cachectica, 


. 263 


Purpura apyreta, . 


. 255 


lymphatica, 


. 263 


cachectica, 


. 255 


papuliformis, . 


. 263 


■ chronica, 


. 255 


purulenta, 


. 263 


haamorrhagica, 


. 258 


Scabrites unguium, 


. 655 


senilis, 


. 260 


Scalds, .... 


. 285 


simplex, 


. 256 


Scaliger, on the acarus scabiei, 


. 660 


urticans, 


. 259 


Scall, crusted, 


. 212 


Pustulae, Willan's fifth order, 


. 211 


erythematic, . 


. 215 


Pustular eruptions, 


. 210 


humid, .... 


. 185 


Pustule, definition of, . 


. 211 


papulous, 


. 220 






running, 


185, 200 


Rainbow ringworm, 


. 230 


vesicular, 


. 200 


Raspail, on the acarus scabiei, 


. 666 


Scalled head, 


. 633 


Red-gown, or red-guin rash, 


. 174 


Scalp, diseases of the, . 


. 599 


Remedies for the skin, . 


. 1111 


alopecia, 


. 605 


Renucci, M , on the acarus scabie 


i, . 666 


canities, 


. 613 


Rete Malpighianum, 


. 33 


eczema capitis, 


. 200 


Rete mucosum, 


. 33 


erysipelas 


. 135 


Retro-vaccination, 


. 503 


favus, .... 


. 637 


Revaccination, 


. 500 


impetigo figurata, . 


. 216 


Ringworm, common, 


. 617 


sparsa, 


. 217 


crusted, . 


. 637 


inflaminatio folliculorum, 


. 633 


honeycomb, . 


. 637 


lepra vulgaris, 


. 305 


impetiginous, . 


. 214 


narcosis folliculorum, 


. 632 


rainbow, 


. 235 


pityriasis capitis, . 


125, 201 


vesicular, 


. 230 


psoriasis oapil is, 


. 201 


Rosa 


. 1 3 1 


stearrhcea folliculorum, . 


. 632 


Rosalia, vide rubeola, . 


. 432 


briohosis furfuraoea, 


. 617 


Boseola, .... 


. Ill 


plica, 


. 628 


asstiva, .... 


. [45 


Soarfekin 


. 33 


annulata, . 


. L46, 387 


Scarlatina 


. 441 


arthritioa, 


. 1511 


anginosa, . . . 


. 443 


autnmnalis, . 


. M6 


benigna. 


. 441 


i ica, 


. LSI 


erethrioa, 


. 44 1 


febris oonl jnuaB, 


. 151 


gravior, vide maligna, . 


. 444 


infantilis, 


. 14. r 


laevigata, 


. 442 


miliarie, .... 


. 161 


maligna, 


. 444 



692 


IN D B X. 






PAGE 


1-AfJE 


S sarlatina, milliforniis, 


. 442 


Steatozoon folliculorum, 


62 


niitior, vide auginosa, . 


. 443 


Stigmata, 


. 254 


nervosa, ..... 


. 444 


Stimulant remedies, 


. 106 


papulosa, .... 


. 442 


Stone-pock, . 


. 538 


phlyctaenosa 


. 442 


Strophulus, . 


94, 174 


plana, 


. 442 


albidus, 


. 176 


putrida, 


. 444 


candidus, 


. 176 


pustulosa, .... 


. 442 


confertus, 


. 175 


septica, 


. 444 


intertinctus, . 


. 174 


sequelae of, . 


. 446 


rotations, 


. 180 


simplex, .... 


. 441 


Sty, or Stigh, 


. 247 


sine angina, vide simplex. 




^udamina, 


. 203 


sine eruptione, 


. 445 


Sudatoria, 


. 542 


sine exanthemate, . 


. 445 


maligna, 


. 544 


torpida, ..... 


. 444 


miliaria, 


. 543 


treatment of, . 


. 451 


partialis, 


. 543 


vesicular is, . 


. 442 


simplex, 


. 543 


Scarlet fever, .... 


. 441 


Sudoriparous glands, 


. 49 


Sohaeffer, on the aearus scabiei, . 


. 669 


disorders of, . 


. 542 


Scorbutic eruption, 


. 254 


Sunburn, 


537 


Scrofuloderma 


322 


Swine-pox, 


. 481 


treatment of, . 


.' 323 


Sycosis, 


. 634 


ungueale, .... 


. 322 


contagiosum, 


. 635 


Scrofulous tubercles. 


. 322 


Syphilis, erythematous, 3 


16, 386, 405, 407 


Scrofulous ulcers, .... 


322 


hereditary. 


. 412 


Sou ivy. ..... 


258 


infantile, 


. 412 


Sebaceous accumulations. 


583 


lupiform, 


. 409 


flux, ....§. 


. 631 


papular, 


. 390 


secretion of, . 


75 


pustular, 


. 399 


alteration of, . 


561 


secondary, 


. 386 


augmentation of, 


555 


teitiary, 


. 404 


composition of. 


7.") 


treatment of, . 


. 417 


diminution of, 


.". 5 1 i 


tubercular, 


. 390, 404 


retention of, . 


570 


Syphilitic eruptions, 


. 382 


tubercles, miliary, . 


590 


ecthyma, 


. 400 


tumors, encysted, . 


59 i 


fever, 


. 382 


small, .... 


590 


lepra, 


307, 397, 417 


Sebiferous ducts, .... 


53 


lichen, . . . • 


. 388 


Sebiparous glands, 


52 


maculae, . 


. 387 


diseases of, . 


555 


papula?, . 


. 388 


Seborrbcea, .... 555, 5(3 


1, 632 


psoriasis, 


. 412 


Sensibility of the skin, . 


72 


pustules, 


.. 399 


Serous cysts, ..... 


. 591 


roseola, . 


. 386 


Serres, Bretonneau, and Velpeau, MM. 




rupia, 


. 399 


treatment of variola, 


474 


tubercles, 


. 390 


Shingles, ..... 


228 


Sypbiloderma, . . 31 


6, 386, 405. 407 


Simon, Dr. G , aearus folliculorum, 


673 


erythematosus, 


. ' 386 


Skin, sensibility of, 


72 


hwreditarium, 


. 411 


absorbing power of, 


73 


papulosum, 


. 388 


anatomy of, . 


33 


pilare, 


. 4»3 


pathology of, . 


91 


pustulosum, . 


. 399 


physiology of, . 


72 


tuberculosum,. 


. 390, 407 


Small-pox 


459 


ulcerans, 


. 410 


inoculated. .... 


465 


ungueale, 


. 403 


modified, vide varicella, 


478 


Syphiloderinata, . 


. 382 


spurious, .... 


478 


classified table of, . 


. 385 


pathology of, . 


467 


hereditaria, . 


. 412 


Soft corns, 


523 


mitigata, 


. 385 


Spasmus periphericus, . 


35 


primitiva, 


. 386, 404 


Spedalskhed, .... 


335 






Spiloplaxia indica, 


340 Tar and pitch as remedies, . 


. 109, 114 


Spilus. 53 


4, 60] Teleangiectasia, 


. 510 


Squamae, Wilburs second order, . 


298 


Terminthus, . . . . 


. 244, 248 


Squamous diseases, 


1".!.. 


Tertiary syphilis, . 


. 404 


Squarra tondens 


617 Tetter, 


. 224 


Sfcearrhoea flavescens, . . . . 


561 crusted, . . . . 


. 212 


folliculorum, .... 63 


i, 632 diffused, . . . . 


. 300 


nigricans, .... 


561 dry 


. 300 


simplex, 


555 humid, . 


. 185 


Steatoma, ..... 


592 


Therapeutics of the skin, 


. 97 



INDEX. 



Thomson, Hale, on mollusc u 
Tilesius, case of molluscum. 
Tinea amiantacea, 

capitis, . 

favosa, . 

furfuracea, 

granulata, 

lactea, 

lupinosa, 

maligna, 

mucosa, 

nummularis, 

tondens, . 
Tooth rash, . 
Touch, . 
Trichiasis ciliorum, 

coacta, . 
Trichogenous remedies, 
Trichomonas vaginalis, 
Trichomyces tonsurans, 
Trichophyton tonsurans 
Trichosis cana, 

decolor, . 

furfuracea, 

hirsuties, 

plica, 

poliosis, . 
Tsorat, . 
Tubercles, cupped, 

miliary, . 

pearly. . 

syphilitic, 
Tubercula, 

miliaria, 

mucosa, . 

sebacea, . 

syphilitica, 
annulata, 
circumscripta, 
corymbosa, 
disseminata, 
gummata, 
lupoidea, . 
mucosa, . 
ulcerantia, 
iulea 1'igarres, 
Tuberculum ma lignum. 
Tutnore:- gummati, 

sabacei, . 

serosi, 
Tumors, atheromatous, 

encysted, 

erectile, , 

follicular, 

gum ma ted, 

melicerous, 
li i arous, 

Bteatomatous, • 
Turkish bath, 
Tylosis, . 
Tyriu, . 

Ungues adunci, 
i redo, . 
Urticaria, 

al. ingestis, 

oooferta, 
evanida, 
febrilis, . ' . 

perstnns, 



PAGE 

583 
576 
200 
617 
637 
200 
189, 200. 216 

189, 216 
637 
637 

1S9, 216 
617 
617 
174 
72 
611 
611 

610, 683 
675 
617 
621 
613 
611 
617 
600 
628 
613 

299, 304 
390 
590 
590 
390 
298 
590 
407 



397 
392, 393 
392 
395 
409 
413 
407 
399, 408 
565 
597 
409 
591 
591 
591 
591 
510 
591 
109 
591 
573 
591 
73 
521 
374, 606 

65 I 
1 63 
153 
165 
[65 
155 
1 54 
156 



Urticaria, subcutanea, 
tuberosa, 

Vaccination, 

tests, 
Vaccinella, . 
Vaccinia, 

Vallecula unguis, . 
Varicella, 

cellulosa, 

coniformis, 

globularis, 

lentiformis, vide ve 

lymphatiea, vide ve 

papillaris, 

sine varicellis, 

umbilicated pustuis 

verrucosa, 

vesicularis, 
Varicose venules, . 
Variola, 

coherens, 

confluens, 

discreta, 

inoculated, 

insert a, . 

lymphatiea, 

modified, vide varic 

nervous, 

pathology of, . 

secondary, 

sine variolis, . 

spurious, 

treatment of, . 

vaccina, 
Variolation, . 
Variolar crystalline, 

pusillse, . 

vaccina;, 

verninosae, 

verrucosa, 
Varioloid, vide varicella 
Variolo- vaccination, 
Varus, . 

Vascular na;vus, . 
Veins, hypertrophy, 
Vellarine, 

Velpeau, treatment of e 
Verruca, 

achrocordon, . 

conduens, 

digitata, 

lobosa, . 

maligna, 

sessilis, . 
Vesicuhe, 
Vesicular eruptions, 

ringworm, 
Vibices, 
Vienna paste, 
Vi^o plaster in variola, 
Vitiligo, 

alba, 
Vitiligoidea, 

Warts, . 

Washerwoman's itch, 
Weber's experiments, 
Wen, . 
Whealworm, . 


sicnli 
sicul 

r, 
ella. 

rysip 


ris, 
iris, 

elas, 


47 

46 

46 

47 
47 


PAGE 

. 156 
. 156 

. 493 
. 499 
. 495 
. 484 
6S 
8, 480 
. 480 
. 481 
. 480 
. 482 
. 4S2 
. 482 
. 482 
. 480 
. 482 
. .482 
. 508 
. 459 
. 460 
. 460 
460 
1), 465 
465 
47S 

472 
467 
460 

0, 466 
478 
471 
484 
503 

. 478 
478 
484 
482 

3, 482 

3, 4S0 
503 
593 
510 
50S 
368 
143 
51 S 
518 
519 
519 
519 
598 
518 
182 
182 
230 
254 
321 
475 
317 
340 
555 

518 
171 

72 
591 

277 



694 



PAGE 

White blisters 239 Xeroderma, ichthyoides, 

Whitlow 658 

Wichmann, on the acarns Beabiei, . . 663 Zinc ointment, benzoated, 

Williams, Dr. Robert, treatment of ery- Zittman's decoction, 

sipelas. ..... 139 ' treatment of syphilis, 

Witt, Dr., treatment of scarlatina. . 471 Zona, .... 

herpetica, 

Xerasia, 604 , ignea, 

Xeroderma, 556 Zoster 



104. 682 

. 419 

. 417 

. 228 

. 230 

. 228 

. 228 



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A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. 

Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third 
and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 50. 
The most useful practical work on the subject in I The most able, and certainly the most standard 
the English language. — Boston Med. and Surg, and practical, work on female diseases that we ha v« 
Journal. | yet seen.— Medico-C kirurgical Review. 



ARNOTT (NEILL), M. D. 
ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. 

Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays 
M. U. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- 
tions. $2 25. 



BARLOW (GEORGE H.), M.D. 

Physicinn to Guy's Hospital, London, Ice. 

A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. 

F. Condie, M.D., uuthor of" A Practical Treatise on Diseases of Children, "(fee. In one hand- 
some octavo volume, extra cloth, of over 600 pages. $2 50. 



We recommend Dr. Biirlow'sMunuul in the warm- I 
68t manner as a most valuable vade-mecum. We 
have hud frequent occasion to consult it, and have I 



found it clear, concise, practical, and sound — Bi 
ton Med. and Surg. Journal. 



BUCKLER ON TIIK BTIOLOGY,PATHOLOGY 

AND TREATMENT OF I'l ISKO-IIRONCHI- 
TI8 \M> RHEUMATIC PNEUMONIA. Ir 

one 8vo. volume, extra cloth, pp.150. SI '25. 
BRODIE'S CLINICAL LECTURES ON SUR 

GERY. t vol. 8vo. cloth. 350pp. *1 25 
BIRD ON URINARY DEPOSITS See Roberts 

on Urinary Diseases, p. 'H. 



BLOOD AND URINE (MANUALS ON) BY 
J. W. GRIFFITH, G. o. REESE AND A 
MARKWIOK. One volume, royal l/.no!, extm 
olotfc, wiih plates, pp.400. »i 25. 

HEALE ON THE LAWS OF HEALTH IN RK 
LATION TO MIND AND BODY In „ne vol 
royal l2mo., extra cloth, pp. 2UB. 80 cents. 



HENRY C. LEA'S MEDICAL 



BUDO (GEORGE), M. D., F. R. S., 

Professor of Medicine in King's College, London. 

ON DISEASES OP THE LIVER. Third American, from the third and 

enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- 
fully colored plates, and numerous wood-cuts. pp. 500. $4 00. 



Has fairly established for itself a place among the 
classical medical literature of England. — British 
and Foreign Medico-Chir. Review. 

Dr. Budd'8 Treatise on Diseases of the Liver is 
now a standard work in Medical literature, and dur- 
ing the intervals which have elapsed between the 



successive editions, the author has incorporated into , Lor ,don Med _ Times and Gazette. 



the text the most striking novelties which have cha- 
racterized the recent progress of hepatic physiology 
and pathology: so that although the size of the book 
is not perceptibly changed, the history of liver dis- 
eases is made more complete, and is kept upon a level 
with the progress of modern science. It is the best 
>rk on Diseases of the Liver in any language. — 



BUCKNILLU. C), M.D., and DANIEL H. TUKE, M.D., 

Medical Superintendent of the Devon Lunatic Asylum. Visiting Medical Officer to the York Retreat. 

A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, 

Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With 
a Plate. In one handsome octavo volume, of 536 pages, extra cloth. $4 25. 
The increase ot mental disease in its various forms, and the difficult questions to which it is 
constantly giving rise, render the subject one of daily enhanced interest, requiring on the part of 
the physician a constantly greater familiarity with this, the most perplexing branch of his profes- 
sion. Yet until the appearance of the present volume there has been for some years no work ac- 
cessible in this country, presenting the results of recent investigations in the Diagnosis and Prog- 
nosis of Insanity, and the greatly improved methods of treatment which have done so much in 
alleviating the condition or restoring the health of the insane. 



BENNETT (HENRY), M. D. 
A PRACTICAL TREATISE ON INFLAMMATION OP THE UTERUS, 

ITS CEKVIX AND APPENDAGES, and on its connection with Uterine Disease. Sixth 

American, from the fourth and revised English edition. In one octavo volume, of about 500 

pages, extra cloth. $3 75. (Just Issued.) 

This standard work, which has done so much to introduce the modern and improved treatment 
of female diseases, has received a very careful revision at the hands of the author In his preface 
he states : " During the past two years this revision of former b bors has been my principal occupa- 
tion, and in its present state the work may be considered to embody the matured experience of the 
many years I have devoted to the study of uterine disease." 

BRINTON (WILLIAM), M. D F. R. S„, 

Physician to St. Thomas's Hospital. 

LECTURES ON THE DISEASES OF THE STOMACH, with an introduc- 

Hon on its Anatomy and Physiology. From the second and enlarged London edition. With 
illustrations on wood. In one large and handsome octavo volume. $3 25. (Just Ready.) 



The entire series of lectures embraced in the 
volume before us are well worthy of a close study 
on the part of every one desirous of acquiring cor- 
rect views in relation to the nature and treatment 
of the diseases of the stomach. Nowhere can be 
found a more full, accurate, plain, and instructive 
history of these diseases, or more rational views 
respecting their pathology and therapeutics— Ame- 
rican Journal of the Med. Sciences, April, 1865. 

This is no mere c< mpilation, no crude record of 
cases, but the carefully elaborated production of an 



accomplished physician, who, for many years, has 
devoted special attention to the symptomatology, 
pathology, and treatment of gastric diseases. — 
Edinburgh Med. Journal. 

Dr. Brinton's position as a laborer in medical 
science and a medical author is fully established, 
and these lectures have only added to a reputation 
based on many solid grounds. The work is an im- 
portant one, and we argue for it a great place in 
medical literature. — London Lancet, Dec. 3, 1864. 



BOWMAN (JOHN E.), M.D. 
PRACTICAL HANDROOK OF MEDICAL CHEMISTRY. Edited by C. 

L. Bloxam. Fourth American, from the fourth and revised English Edition. In one neat volume, 
royal 12mo., extra clolb with numerous illustrations, pp.351. $225. 



jeet in view lucidly detailed and explained. And 
this new edition is not merely a reprint of the last. 
With a laudable desire to keep the book up to the 
scientific mark of the present age, every improve- 
ment in analytical method has been introduced. In 
conclusion, we would only say that, familiar from 
long acquaintance with each page of the former 
issues of this little book, we gladly place beside 
them another presenting so many acceptable im- 
provements and additions. — Dublin Medical Press. 



with numerous illustrations. 

Of this well-known handbook we may say that 
it retains all its old simplicity and clearness of ar- 
rangement and description, whilst it has received 
from the able edit <r those finishing touches which 
the progress of chemistry has rendt red necessary — 
London Med. Times and Gazette, Nov. 29, 1862. 

Nor is anything huiriedover, anything shirked ; 
open the book where you will, you find the same 
careful treatment of the subject manifested, anu the 
best process for the attainment of the particular ob- 

BY THE SAME AUTHOR. 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- 

LYSIS. Third American, from the third and revised London edition. With numerous illus- 
trations. In one neat vol., royal 12mo., extra cloth. S'i 25 

This favorite little manual has received a very thorough and careful revision at the hands of a 
competent editor, and will be found fully brought up to the present condition of chemical science. 
Many portions have been rewritten, the subjects of the blow-pipe and volumetric analysis have re- 
ctivod special attention, and an additional chapter has been appended. Students of practical chem- 
istry will therefore find it, as hereiofore, a most convenient (Mid condensed text-book and guide in 
the operations of the laboratory. 



AND SCIENTIFIC PUBLICATIONS. 



BUMSTEAD (FREEMAN J ) M . D., 

Lecturer on Venereal Diseases at the College of Pnysicians and Surgeons, New York, &c. 

THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, 

including the results of recent investigations upon the subject. Second edition, thoroughly re- 
vised and much improved. With illustrations on wood. In one very handsome octavo volume, 
of about 700 pages. §5 00 (Just Issued.) 



By far the most valuable contribution to this par- 
ticular branch of practice that has seen the light 
within the last score of years. His clear and accu- 
rate descriptions of the various forms of venereal 
disease, and especially the methods of treatment he 
proposes, are worthy of the highest encomium. In 
these respects it is better adapted for the assistance 
of the every-day practitioner than any other with 
which we are acquainted. In variety of methods 
proposed, in minuteness of direction, guided by care- 
ful discrimination of varying forms and complica- 
tions, we write down the book as unsurpassed. It 
is a work which should be in the possession of every 
practitioner.— Chicago Med. Journal. Nov. 1861. 

Tne foregoing admirablevolumecomes to us, em- 
bracing the whole subject of syphilology, resolving 
many a doubt, correcting and confirming many an 
entertained opinion, and in our estimation the best, 
completest, fullest monograph on this subject in our 
language. As far as the author's labors themselves 
are concerned, we feel it a duty to say that he has 
not only exhausted his subject, but he has presented 
to us, without the slightest hyperbole, the best di- 
gested treatise on these diseases in our language. 
He has carried its literature down to the present 
moment, and has achieved his task in a manner 
which cannot but redound to his credit. — British 
American Journal, Oct. 1861. 

We believe this treatise will come to be regarded 
aB high authority in this branch of medical practice, 
and we cordially commend it to the favorable notice 
of our brethren in the profession. For our own part, 
we candidly confess that we have received many 
new ideas from its perusal, as well as modified many 
views which we have long, and, as we now think, 
erroneously entertained on the subject of syphilis. 



To sum up all in a few words , this book is one which 
no practising physician or medical student can very 
well afford to do without. — American Med. Times, 
Nov. 2, 1861. 

The whole work presents a complete history of 
venereal diseases, comprising much interesting and 
valuable material that has been spread through med- 
ical journals within the last twenty years — the pe- 
riod of man) 7 experiments and investigations on the 
subject — the whole carefully digested by the aid of 
the author's extensive personal experience, and 
offered to the profession in an admirable form. Its 
completeness is secured by good plates, which are 
especially full in the anatomy of the genital organs. 
We have examined it with great satisfaction, and 
congratulate the medical profession in America on 
the nationality of a work that may fairly be called 
original. — Berkshire Med. Journal, Dec. 1861. 

One thing, however, we are impelled to say, that 
we have met with no other book on syphilis, in the 
English language, which gave so full, clear, and 
impartial views of the important subjects on which 
it treats. We cannot, however, refrain from ex- 
pressing our satisfaction with the full and perspicu- 
ous manner in which the subject has been presented, 
and the careful attention to minute details, so use- 
ful — not to say indispensable — in a practical treatise. 
In conclusion, if we may be pardoned the use of a 
phrase now become stereotyped, but which we here 
employ in all seriousness and sincerity, we do not 
hesitate to express the opinion that Dr. Buinstead's 
Treatise on Venereal Diseases is a " work without 
which no medical library will hereafter be consi- 
dered complete."— Boston Med. and Surg. Journal 
Sept. 5, 1861. 



BARCLAY (A. W.), M . D., 

Assistant Physician to St. George's Hospital, &c. 

A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs 

and Symptoms of Disease. Third American from the second and revised London edition. In 

one neat oclavo volume, extra cloth, of 451 pages. $3 50. 

The demand for another edition of this work shows that the vacancy which it attempts to sup- 
ply has been recognized by the profession, and that the efforts of the author to meet the want have 
been successful. The revision which it has enjoyed will render it better adapted than before to 
aflbrd assistance to the learner in the prosecution of his studies, and to the practitioner who requires 
a convenient and accessible manual for speedy reference in the exigencies of his daily duties. For 
this latter purpose its complete and extensive Index renders it especially valuable, offering facilities 
for immediately turning to any class of symptoms, or any variety of disease. 

The task of composing such a work is neither an We hope the volume will have an extensive ci r • 
easy nor a light one; but Dr. Barclay has performed 
it in a manner which meets our most unqualified 
approbation. He is no mere theorist; he knows his 
work thoroughly, and in attempting to perform it, 
has not exceeded his powers. — British Med. Journal. 



We venture to predict that the work will be de- 
servedly popular, and soon become, like Watson's 
Practice, an indispensable necessity to the practi- 
tioner— N. A. Med. Journal. 

An inestimable work of reference for the young 
practitioner and student. — Nashville Med. Journal. 



culation, not among students of medicine only, but 
practitioners also. They will never regret a faith- 
ful study of its pages. —Cincinnati Lancet. 

An important acquisition to medical literature. 
It is a work of high merit; both from the vast im- 
portance of the subject upon which it treats, and 
aUo from the real aDility displayed in ; t« elabora- 
tion. In conclusion, let us bespeak for this volume 
that attention of every student of our art which it 
so richly deserves— that place in evury medical 
library which it cun so well adorn.- Peninsular 
Medical Journal . 



BARTLETT (ELISHA), M. D. 

THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS 

OF THE UNITED STATES. A new uud revised edition. By Alonzo Clark, M. D., Prof, 
oi Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, <tec. In 
one oclavo volume, of six hundred pages, extra cloth. Price S4 25. 



BROWN (ISAAC BAKER), 
Surgeon- AccoucheuT to St. Mary's Hospital, Ice. 

ON SOME DISEASES OF WOMIwN ADMITTING OF SURGICAL TREAT- 

MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp. 276. $160. 

Mr. Brown has earned for himself a nigs reputa- I and merit the careful attention of every surgeon 
tion in the operative treatment of sundry diseases accoucheur. —Association Journal. 
and injuries to which fe males a re pecu I iarly subject. 
We. c;in truly say of hil work that it is un important 
addition t<> obstetrical literature. The operative 



suggestions and contrivances which Mr. Brown de- 
scribes, exhibit much practical sagacity and skill 



Wc have no hesitation in recommending this book 
to t!ie careful attention of all surgeons who make 
female oomplaints a part of their study aiu' practice. 
— Dublin (.Quarterly Journal, 



HENRY C. LEA'S MEDICAL 



BRANDE (WM. T.) D. C. 
Of her Majesty's Mint, &c. 



a>d ALFRED S. TAYLOR, M. D., F. R. S. 

Professor of Chemistry and Medical Jurisprudence in 
Guy's Hospital. 

CHEMISTRY. In one handsome 8vo. volume of 696 pages, extra cloth. $4 50. 

" Having been engaged in teaching Chemistry in this Metropolis, the one for a period of forty, 
and the oilier for a period of thirty years, it has appeared to us that, in spite of the number of books 
already existing, there was room for an additional volume, which should be especially adapted lor 
the n-e of students. In preparing such a volume for the press, we have endeavored to bear in 
mind, that the student in the present day has much to learn, and but a short time at his disposal for 
the acquisition of this learning." — Authors' Preface. 

In reprinting this volume, its passage through the press has been superintended by a competent 
chemist, who has sedulously endeavored to secure the accuracy so necessary in a work of this 
nature. No notes or additions have been introduced, but the publishers have been favored by the 
auihors with some corrections and revisions of the first twenty-one chapters, which have been duly 
inserted. 

In so progressive a science as Chemistry, the latest work always has the advantage of presenting 
the subject as modified by the results of the latest investigations and discoveries. That this advan- 
tage has been made the most of, and lhat the work possesses superior attractions arising from its 
clearness, simplicity of style, and lucid arrangement, are manifested by the unanimous testimony 
of the English medical press. 

It needs no great sagacity to foretell that this book and left at the affectation, mysticism, and obscurity 
will be, literally, the Handbook in Chemistry of the -which pervade some late chemical treatises. Thus 
student and practitioner. For clearness of language, conceived, and worked out in the most sturdy, corn- 
accuracy of description, extent of information, and mon sense method, this book gives, in the clearest and 
freedom from pedantry and mysticism of modern most summary method possible, all the facts and doc- 
chemistry, no other text-book comes into competition ! triues of chemistry, with more especial reference to> 
with it. The result is a work which for fulness of j the wants of the medical student. — London Medical 
matter, for lucidity of arrangement, for clearness of 
Btyle, is as yet without a rival. And long will it be 
without a rival. For, although with the necessary 



advance of chemical knowledge addenda will 
quired, there will be little to take away. The funda- 
mental excellences of.the book will remain, preserv- 
ing it for years to come, what it now is, the best guide 
to the study of Chemistry yet given to the world.— 
London Lancet, Dec. 20, lSti2. 

Most assuredly, time has not abated one whit of the 
fluency, the vigor, and the clearness with which they 
not only have composed the work before us. but have 



Times and Gazette, Nov. 29, 1S62. 

If we are not very much mistaken, this book will 
occupy a place which none has hitherto held among 
chemists ; for, by avoiding the errors of previous au- 
thors, we have a work which, for its size, is certainly 
the most perfect of any in the English language. 
There are several points to be noted in this volume 
which separate it widely from any of its compeers — 
its wide application, not to the medical student only, 
nor to the student in chemistry merely, but to every 
branch of science, art, or commerce which is in any 
way connected with the domain of chemistry. — Lon- 



so to say, cleared the ground for it, by hitting right i donMtd. Review, Feb. 1S03. 



BARWELL (RICHARD,) F- R. C. S., 

Assistant Surgeon Charing Cross Hospital, &c. 

A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engrav- 
ings on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $5 00. 
At the outset we may state that, the work is [ ing and faithful delineations of disease. — London 

worthy of much praise, and bears evidence of much ' "" 

thoughtful and careful inquiry, and here and there 

of no slight originality. We have already carntd 



this notice further than we intended to do, but not 
to the extent the work deserves. We can only add, 
that the perusal of it has afforded us great pleasure. 
The author has evidently worked very hard at his 
subject, and his investigations into the Physiology 
and Pathology of Joints have been carried on in a 
manner which entitles him to be listened to with 
attention arid respect. We must not omit to men- 
tion the very admirable plates with which the vo- 
lume is enriched. We seldom meet with such strik- 



Med. Times and Gazette, Feb. 9, 18(51. 

This volume will be welcomed, as the record of 
much honest research and careful investigation into 
the nature and treatment of a most important class 
of disorders. We cannot conclude this notice of a 
valuable and useful book without calling attention 
to the amount of bona fide work it contains. It is no 
slight matter for a volume to show laborious inves- 
tigation, and at the same time original thought, on 
the part of its author, whom v e may congratulate 
on the successful completion of his arduous task. — 
London Lancet, March 9, lbtH. 



CARPENTER (WILLIAM BJ, M. D., F. R. S., &.C., 

Examiner in Physiology and Comparative Anatomy in the University of London. 

THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- 
taining the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M. D. 
Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very* 
handsome octavo volume, of 724 pages, extra cloth, f 5 25. 

The great importance of the microscope as a means of diagnosis, and the number of microsco- 
pists who are also physicians, have induced the American publishers, with the author's approval, to 
add an Appendix, carefully prepared by Professor Smith, on the applications of Ihe instrumeni to 
clinical medicine, together with an account of American Microscopes, their modifications and 
accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is 
hoped, will adapt the volume more particularly to the use of the American student. 

The additions by Prof. Smith give it a positive 
claim upon the profession, for which we doubt not 
he will receive their sincere thanks. Indeed, we 



Those who are acquainted with Dr. Carpenter's 
previous writings on Animal and Vegetable Physio- 
logy, willfully understand how vast a store of know- 
ledge he is able to bring to bear upon so comprehen- 
sive a subject as the revelations of the microscope; 
and even those who have no previous acquaintance 
with the construction or uses of this instrument, 
will find abundance of information conveyed in clear 
and simple language.— Med. Tinui and Gazette . 



know not where the student of medicine will find 
such a complete and satisfactory collection of micro- 
scopic facts bearing upon physiology and practical 
medicine as is contained in Prof. Smith's appendix; 
and this of itself, it seems to us, is fully worth the 
cost of the volume. — Louisville Medita, Review. 



AND SCIENTIFIC PUBLICATIONS. 



CARPENTER (WILLIAM B.>, M. D., F. R. S., 

Examiner in Physiology and Comparative Anatomy in the University of London. 

PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to 

Psychology; Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from 
the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- 
tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- 
vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred 
large pages, handsomely printed, extra cloth, $5 50 

For upwards of thirteen years Dr. Carpenter's | To eulogize thisgreat work wouldbe superfluous, 
work has been considered by the profession gene- I We should observe, however, that in this edition 
rally, both in this country and England, as the most the author has remodelled a large portion of ths 
valuable compendium on the subject of physiology former, and the editor has added much matter of in- 
in our language. This distinction it owes to the high terest, especially in the form of illustrations. We 
attainments and unwearied industry of its accom- may confidently recommend it as the most complete 
plished author. Thepresentedition (which, like the i work on Human Physiology in our language. — 
last American one, was prepared by the author him- I Southern Med. and Surg. Journal. 



self) , is the result of such extensive revision, that it 
may almost be considered a new work. We need 
hardly say, in concluding this brief notice, that while 
the work is indispensable to every student of medi- 
cine in this country, it will amply repay the practi- 
tioner for its perusal by the interest and value of its 
c intents. — Boston Med. and Surg. Journal. 

This is a standard work — the text-book used by ali 
medical students who read the English language. 
It has passed through several editions in order to 
keep pace with the rapidly growing science of Phy 
Biology 
mei " 
eay 



The most complete work on the science in our 
language.— Am. Med. Journal. 

The most complete work now extant in our lan- 
guage. — N. O. Med. Register. 

The best text-book in the language on this ex 
tensive subject. — London Med. Times. 

A complete cyclopaedia of this branch of science. 
— JV. Y. Med. Times. 

The profession of this country, and perhaps also 
of Europe, have anxiously and for sometime awaited 
Nothing need be said in its praise, for its i the announcement of this new edition of Carpenters 
merits" are universally known; we have nothing to! Human Physiology. His former editions have for 
r of its defects, for they only appear where the i many years been almost the only text-book on Phy- 
scienee of which it treats is incomplete. — Western Biology in all our medical schools, and its circula- 
Lancet. I tion among the profession has been unsurpassed by 

The most complete exposition of physiology which anv work i. n an >' department of medical science, 
any language can at present give.— Brit, and For. il , ls <l uite unnecessary for us to speak of this 
itild -Chirurg Review work as lts ments would justify. The mere an- 

I nouncement of its appearance will afford the highest 

The greatest, the most reliable, and the best book j pleasure to every student of Physiology, while iti 

on the subject which we know of in the English I perusal will be of infinite service in advancing 

language.— Stethoscop*. '■ physiological science.— Ohio Med.andSurg. Jov.rn. 



BY THE SAME AUTHOR. 

ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- 
LOGICAL ANATOMY. Second American, from a new and revised London edition. With 
one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. 
$4 00. 

in publishing the first edition of this work, its title was altered from that of the London volume, 
by the substitution of the word " Elements" for that of " Manual," and with the author's sanction 
the title of " Elements" is still retained as being more expressive of the scope of the treatise. 

BY THE SAME AUTHOR. 

PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from 

the Fourth and Revised London edition. In one large and handsome octavo volume, with over 
three hundred beautiful illustrations, pp. 752. Extra cloth, $5 00. 



This book should not only be read but thoroughly 
studied by every member of the profession. None 
are too wise or old, to be benefited thereby. But 
especially to the younger class would we cordially 
commend it as best fitted of any work in the English 
language to qualify them for the reception and com- 
prehension Of those truths which arc daily being de- 
veloped in physiology. — Medical Counsellor. 

Without pretending to it, it is an encyclopedia of 
the subject, accurate and complete in all respects — 
a truthful reflection of the advanced state at which 
the science has now arrived. — Dublin Quarterly 
Journal of Medical Scienct. 

A truly magnificent work — in itself a perfect phy- 
siological study.— Ranlcing's Abstract. 

This work stands without its fellow. It is one 
few men in Europccould have undertaken ; it is one 



no man, we believe, could have brought to so suc- 
cessful an issue as Dr. Carpenter. It required for 
its production a physiologist at once deeply read in 
the labors of others, capable of taking a general, 
critical, and unprejudiced view of those labors, ana 
of combining the varied, heterogeneous materials at 
his disposal, so as to form an harmonious whole. 
We feel that this abstract can give the reader a very 
imperfect idea of the fulness of this work, and no 
idea Of its unity, of the admirable mai ner in which 
material has been brought, from the most various 
sources, to conduce to its completeness of the lucid- 
ity of the reasoning it contains, or of the clearness 
(il language in which the whole is clothed. Not the 
profession only, but the scientific world at large, 
must feel deeply indebted to Dr. Carpenter for this 
great work. It must, indeed, add lurgely even to 
his high reputation. — Medical Timts. 



BY THE SAME AUTHOR. (Prr.pari.7ig.) 

PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC 

CHEMISTRY AND HISTOLOGY. Willi a General Sketch, ol the Vegetable and Animal 
Kingdom. In one lurge and very handsome octavo volume, with several hundred illustrations* 

BY THE SAME AUTHOR. 

A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH 

AND DISEASE New edition, with a Preface by D. F. Condie, M. D., and explanation- ol 
scientific words. In one neat 12ruo. volume, extra cloth, pp. 178 60 cents. 



HENRY C. LEA'S MEDICAL 



CONDIE (D. F.), M. D., Sec. 
A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth 

edition, revised and augmented. In one large volume, Svo., extra cloth, of over 750 pages. S4 50. 

In presenting a new and revised edition ot this favorite work, the publishers have only to state 
that the author has endeavored to render it in every respect "a complete and faithful exposition of 
the pathology and therapeutics of the maladies incident to the earlier stages of existence — a full 
and exact account of the diseases of infancy and childhood." To accomplish this he has subjected 
the whole work to a careful and thorough revision, rewriting a considerable portion, and adding 
several new chapters. In this manner it is hoped that any deficiencies which may have previously 
existed have been supplied, that the recent labors of practitioners and observers have been tho- 
roughly incorporated, aid that in every point the work will be found to maintain the high reputation 
it has enjoyed as a complete and thoroughly practical book of reference in infantile affections. 

A few notices of previous editions are subjoined. 



Dr. Oondie's scholarship, acumen, industry, and 
practical sense are manifested in this, as in all his 
numerous contributions to science. — Dr. Holmes's 
Report to the American Medical Association. 

Taken as a whole, in our judgment, Dr. Condie's 
Treatise is the one from the perusal of which the 
practitioner in this country will rise with the great- 
est satisfaction— Western Journal of Medicine and 
Surgery. 

One of the best works upon the Diseases of Chil- 
dren in the English language. — Western Lancet. 

We feel assured from actual experience that nc 
physician's library can be complete without a copy 
of thiswork. — N. Y. Journal of Medicine. 

A veritable paediatric encyclopaedia, and an honor 
to American medical literature. — Ohio Medical and 
Surgical Journal. 

Wefeel persuaded thatthe American medical pro- 
fession will soon regard it not only as a very good, 
but as the very best "Practical Treatise on the 
Diseases of Children." — American Medical Journal 

In the department of infantile therapeutics, the 
work of Dr. Conaie is considered one of the best, 
which has been published in the English language. 
— The Stethoscope. 



We pronounced the first edition to be the heel 
work on the diseases of children in the English 
language, and, notwithstanding all that has been 
published, we still regard it in that light. — Medical 
Examiner. 

The value of works by native authors on the dis- 
eases which the physician is called upon to combat, 
will be appreciated by all j and the work of Dr. Con- 
die has gained for itself the character of a safe guide 
for students, and a useful work for consultation by 
those engaged in practice. — JV. Y. Med. Times. 

This is the fourth edition of this deservedly popu- 
lar treatise. During the interval since the last edi- 
tion, it has been subjected to a thorough revision 
by the author; and all new observations in the 
pathology and therapeutics of children have been 
included in the present volume. As we said btfore, 
we do not know of a better book on diseases of chil- 
dren, and to a large part of its recommendations we 
yield an unhesitating concurrence.— Buffalo Med. 
Journal. 

Perhaps the mostfulland complete work now be- 
fore the. profession of the United States; indeed, we 
may say in the English language. It is vastly supe- 
rior to most of its predecessors. —Transylvania Med. 
Journal 



CHRISTISON (ROBERT), M . D., V. P. R. S. E., ice. 
A DISPENSATORY; or. Commentary on the Pharmacopoeias of Great Britain 

and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- 
tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- 
proved, with a Supplement containing the most important New Remedies. With copiouls Addi- 
tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M\ D. 
In one very large and handsome octavo volume, extra cloth, of over 1000 pages. $4 CO 



COOPER (BRANSBY BJ, F. R. S. 
LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY- 

In one very large octavo volume, extra cloth, of 750 pages. $2 00. 



COOPER ON THE ANATOMY AND DISRASES 
OF THE BREAST, with twenty-five Miscellane- 
ous and Surgical Papers. One large volume, im- 
perial bvo., extra cloth, with 252 figures, on 36 
plates. 83 00. 

COOPER ON THE STRUCTURE AND DIS- 
EASES OF THE TESTIS, AND ON THE 
THYMUS GLAND. One vol. imperial 8vo., ex- 
tra cloth, with 177 figures on 20 plates. S2 50. 



CLYMER ON FEVERS; THEIR DIAGNOSIS; 
PATHOLOGY, AND TREATMENT. In one 
octavo volume, leather, of 600 pages. $1 75. 

COLOMBAT DE L'ISERE ON THE DISEASES 
OF FEMALES, and on the special Hygiene of 
their Sex. Translated, with many Notes and Ad- 
ditions, by C. D. Meigs, M. D. Second edition, 
revised and improved. In one large volume, oc- 
tavo, leather, with numerous wood-cuts. pp. 720. 
S3 75. 



CARSON (JOSEPH), M.D., 

Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 

SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA 

AND PHARMACY, delivered in the University of Pennsylvania. With three Lectures on 
the Modus Operandi of Medicines. Third edition, revised. In one handsome octavo volume. 
S2 50. 

CURLING (T. B.), F.R.S., 

Surgeon to the London Hospital, President of the Hunterian Society, &o. 

A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- 
TIC CORD, AND SCROTUM. Second American, from the second and enlarged English edi- 
Mon. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. $2 00 



AND SCIENTIFIC PUBLICATIONS. 



CHURCHILL (FLEETWOOD), M. D., M. R. I. A. 
ON THE THEORY AND PRACTICE OP MIDWIFERY. A new American 

from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis 
Condie : M. D., author of a "Practical Treatise on the Diseases of Children," <fcc. With 194 
illustrations. In one very handsome octavo volume, of nearly 700 large pages, extra cloth, $4 00. 
This work has been so long an established favorite, both as a text-book for the learner and as a 
reliable aid in consultation for the practitioner, that in presenting a new edition it is only necessary 
to call attention to the very extended improvements which it has received. Having had the benefit 
of two revisions by the author since the last American reprint, it has been materially enlarged, and 
Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been tho- 
roughly brought up with the latest results of European investigation in all departments of the sci- 
ence and art of obstetrics. The recent date of the last Dublin edition has not left much of novelty 
for the American editor to introduce, but he has endeavored to insert whatever has since appeared, 
together with such matters as his experience has shown him would be desirable for the American 
student, including a large number of illustrations With the sanction of the author he has added 
in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," re- 
cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of 
advantage to the junior practitioner. The result of all these acditions is that the work now con- 
tains fully one-half more matter than the last American edition, with nearly one-half more illus- 
trations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred 
pages more than before. 

No effort has been spared to secure an improvement in the mechanical execution of the work 
equal to that which the text has received, and the volume is confidently presented as one of the 
handsomest that has thus far been laid before the American profession; while the verv low price 
at which it is offered should secure for it a place in every lecture-room and on every office table. 

Were we reduced to the necessity of having but 
>«e work on midwifery, and permitted to choose, 
we would unhesitatingly take Churchill. — Wester* 
ted. and Surg. Journal. 

It is impossible to conceive a more useful and 
slegant manual than Dr. Churchill's Practice of 
Vlidwifery. — Provincial Medical Journal. 



A better book in which to learn these important 
points we have not met than Dr. Churchill's. Every 
page of it is full of instruction; the opinion of all 
writers of authority is given on questions of diffi- 
culty, as well as the directions and advice of the 
learned autnor himself, to which he adds the result 
of statistical inquiry, putting statistics in their pro 
per place and giving them their due weight, and no 
more. We have never read a book more free from 
professional jealousy than Dr. Churchill's. It ap- 
pears to be written with the true design of a book on 
medicine, viz : to give all that is known on the sub- 
ject of which he treats, both theoretically and prac- 
tically, and to advance such opinions of his own as 
he believes will benefit medical science, and insure 
the safety of the patient. We have said enough to 
convey to the profession that this book of Dr. Chur- 
ehill's is admirably suited for a book of reference 
for the practitioner, as well as a text-book for the 
etudent, and we hope it may be extensively pur- 
chased amongst our readers. To them we most 
strongly recommend it. — Dublin Medical Press. 

To bestow praise on a bookthat has received such 
marked approbation would be superfluous. We need 
only say, therefore, that if the first edition was 
thought worthy of a favorable reception by the 
medical public,. we can confidently affirm that this 
will he found much more so. The lecturer, the 
practitioner, and the student, may all have recourse 
to its pages, and derive from their perusal much in- 
terest and instruction in everything relating to theo- 
retical and practical midwifery. — Dublin Quarterly 
Journal of Medical Science . 

A work of very great merit, and such as we can 
confidently recommend to the study of every obste- 
tric practitioner. — London Medical Gazette. 

Few treatises will be found better adapted as * 
text-book for the student, or as a manual for tlu 
frequent consultation of the young practitioner. - 
American Medical Journal. 



Certainly, in our opinion, the very best work on 
he subject which exists.— N. Y. Annalist. 

No work holds a higher position, or is more de- 
serving of being placed in the hands of the tyro, 
the advanced student, or the practitioner. — Medical 
Examiner. 

Previous editions have been received with mark- 
ed favor, and they deserved it; but this, reprinted 
from a very late Dublin edition, carefully revised 
and brought up by the author to the present time, 
does present an unusually accurate and able expo- 
sition of every important particular embraced in 
the department of midwifery. # * The clearness, 
directness, and precision of its teachings, together 
with the great amount of statistical research which 
its text exhibits, have served to place it already in 
the foremost rank of works in this department, of re- 
medial science.— N. O. Med. and Surg. Journal. 

In our opinion, it forms one of the best if not the 
very best text-book and epitomeof obstetric scienca 
which we at present possess in the English lan- 
guage. — Monthly Journal of Medical Science. 

The clearness and precision of style in which it is 
written, and the greatamountof statistical research 
which it contains, have served to place it in the first 
rank of works in this departmentof medical science. 
— N. Y. Journal of Medicine. 

This is certainly the most perfect system extant. 
It is the best adapted for the purposes of a text- 
look, and that which he whose necessities confine 
him to one book, should select in preference to all 
others.— Southern Medical and Surgical Journal. 



BY THE SAME AUTHOR. 

ON THE DISEASES OF INFANTS AND CHILDREN. Second American 

Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In 

one large and handsome volume, extra cloth, of over 700 pages. $4 50. 

In preparing this work a second time for the American profession, the author has spared no 
labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, 
while every portion of the volume has been subjected to a severe scrutiny. The efforts of the 
American editor have been directed to supplying such information relative to matters peculiar 
to this country as might have escaped the attention of the author, und the whole may, there- 
fore, be safely pronounced one of ih<- nioM complete worl<< on the subject accessible to the Ame- 
rican Profession. By an alteration in the size >>l the |>uL r <-, these very extensive additions have 
been accommodated without unduly increasing the size of the work. 

BY THE SAME AUTHOR. 

ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- 
CULIAR TO WOMEN. Selected from the writings ol Britieh Authors previous to the close of 
the Eighteenth Century. In one neat octavo vo'ume, extra cloth, of about 450 pages. $2 50. 



HENRY C . LEA'S MEDICAL 



CHURCHILL FLEETWOOD), M. D., M. R. I. A., «tc 

ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- 
bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- 
cis Condie, M. D., author oi " A Practical Treatise on the Diseases of Children." With nume- 
rous illustrations. In one large and handsome octavo volume, extra cloth, of 768 pages. $4 00. 
This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so 
thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely 
brought up to the most recent condition ot the subject, while the very handsome series of illustra- 
tions introduced, representing such pathological conditions as can be accurately portrayed, present 
a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- 
peared desirable tor the American student have been made bv the editor, Dr. Condie, while a 
marked improvement in the mechanical execution keeps pace with the advance in all other respects 
which the volume has undergone, while the price has been kept at the former very moderate rate. 
It comprises, unquestionably, one of the most ex- ! extent that Br. Churchill does. His, indeed, is the 
act and comprehensive expositions of the present only thorough treatise we know of on the subject: 
state oi medical knowledge in respect to the diseases and it mav be commended to practitioners and stu- 
or women that has yet been published.— Am.Journ. dents as a masterpiece in its particular department. 
Med. Sciences. —Thi Western Journal of Medicine and Surgery. 

This work is the most reliable which we possess | A s a comprehensive manual for students, or a 
on this subject; and is deservedly popular with the work of reference for practitioners, it surpasses any 
profession.— Charleston Med. Journal, July, 1857. ot her that has ever issued on the same subject from 

We know of no author who deserves that appro- ' the British press. — Dublin Quart. Journal. 
bation, on "the diseases of females," to the same I 



DICKSON (S. H.), M. D., 

Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. 

ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- 
peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and 
handsome octavo volume, oi 750 pages, extra cloth. $4 00. 

The steady demand which has so soon exhausted the first edition of this work, sufficiently shows 
that the author was not mistaken in supposing that a volume of this character was needed — an 
elementary manual of practice, which should present the leading principles of medicine with the 
practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detaii 
and fruitless speculations, it embodies what is most requisite for the student to learn, and at the 
same time what the active practitioner wants when obliged, in the daily calls of his profession, to 
reiresh his memory on special points. The clear and attractive style of the author renders the 
whole easy of comprehension, while his long experience gives to his teachings an authority every- 
where acknowledged. Few physicians, indeed, have had wider opportunities for observation and 
experience, and tew, perhaps, have used them to better purpose. As the result of a long life de- 
voled to study and practice, the present edition, revised and brought up to the date of publication, 
will doubtless maintain the reputation already acquired as a condensed and convenient American 
text-book on the Practice of Medicine. 



DRUITT (ROBERT), M.R. C.S., &c. 
THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new 

and revised American from the eighth enlarged and improved London edition. Illustrated with 
four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume 
of nearly 700 large pages, extra cloth, $4 00. 

A work which like Druitt's Surgery has for so many years maintained the position of a lead- 
ing favorite with all classes of the profession, needs no special recommendation to attract attention 
to a revised edition. It is only necessary to state that the author has spared no pains to keep the 
work up to its well earned reputation of presenting in a small and convenient compass the latest 
condition of every department of surgery, considered both as a science and as an art; and that the 
services of a competent American editor have been employed to introduce whatever novelties may 
have escaped the author's attention, or may prove of service to the American practitioner. As 
several editions have appeared in London since the issue of the last American reprint, the volume 
has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and 
improvement. The extent of these additions may be estimated from the fact that it now contains 
about one-third more matter than the previous American edition, and that notwithstanding the 
adoption of a smaller type, the pages have been increased by about one hundred, while nearly two 
hundred and fifty wood-cuts have been added to the former list of illustrations. 

A marked improvement will also be perceived in the mechanical and artistical execution of the 
work, which, printed in the best style, on new type, and fine paper, leaves little to be desired as 
regards external finish; while at the very low price affixed it will be found one of the cheapest 
volumes accessible to the profession. 

This popular volume, now a most comprehensive | nothing of real practical importance has been omit- 
WOrkon surgery, lias undergone many corrections, ted; it presents a faithful epitome of everything re- 
unprovemeuts.and additions, and the principles and ' lating t > surgery up to the present hour. It is de- 
the practice of the art have been brought down to servedly a popular manual, both with the student 
the latest record and observation. Of the operations and practitioner. — London Lancet. Nov. 19, 1859. 
'" surgery itis impossible to speak too highly. The I _ ■ i '.'... . . . ( * . 

1 In closing th is brief notice, we recommend as cor- 
dially as ever this most useful and comprehensive 
hand-book. It must prove a vast assistance, not 
only to the student of surgery, but also to the busy 
practitioner wh< may not have the leisure to devote 
himself to the study of more lengthy volumes. — 
London Med Times and Gazelle, Oct 22, 1859. 



The 
descriptions are so clear and concise, and the illus- 
trations so accurate and numerous, that the student 
can have no difficulty, with instrument inhand, and 
book by his side, over the dead body, in obtaining 
a proper knowledge and sufficient tact in this much 
neglected deparl men t of medical education. — British 
and Foreign Medico-Vhirurg. Review, Jan. I960 

In the present edition the author has entirely re- 
writ len many of the chapters, and has incorporated 
the various.improvements and additions in modem 



In a word, this eighth edition of Br. Bruitt'a 
Manual of Surgery is all that the surgical student 
or practitioner could desire. — Dublin Quarttrlf 



■ urgery. On carefully going over it, we find that | Journal of Med. Sciences, Nov. 1859. 



AND SCIENTIFIC PUBLICATIONS. 



11 



DALTON, JR. (J. C), M. D. 

Professor of Physiology in the College of Physicians, New York. 

A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students 

and Practitioners of Medicine. Third edition, revised, with nearly three hundred illustrations 
on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $5 25. (Just Issued.) 
The rapid demand for another edition of this work sufficiently shows that the author has suc- 
ceeded in his efforts to produce a text-book of standard and permanent value, embodying within 
a moderate compass all that is definitely and positively known within the domain" of Human 
Physiology- His high reputation as an original observer and investigator, is a guarantee thai in 
again revising it he has introduced whatever is necessary to render it thoroughly on a level with 
the advanced science of the day, and this has been accomplished without unduly increasing the 
size of the volume. 

No exertion has been spared to maintain the high standard of typographical execution which has 
rendered this work admittedly one of the handsomest volumes as yet produced in this country. 

It will be seen, therefore, that Dr. Dalton's best own original views and experiments, together with 
efforts have been directed towards perfecting his a desire to supply what he considered some deficien- 
work. The additions are marked by tlie same fea- i cies in the first edition, have already made the pre- 
tures which characterize the remainder of the vol- sent one a necessity, and it will no doubt be even 
ume, and render it by far the most desirable text- more eagerly sought for than the first. That it is 
book on physiology to place in the hands of the not merely a reprint, will be seen from the author's 
student which, so far as we are aware, exists in statement of the following principal additions and 
the English language, or perhaps in any other. We alterations which he has made. The present, like 
therefore have no hesitation in recommending Dr. the first edition, is printed in the highest style of the 
Dalton's book for theclasses for which it is intend- printer's art, and the illustrations are truly admira- 
ed, satisfied as we are that it is better adapted to ble tor their clearness in expressing exactly what 
their use than any other work of the kind to which their author intended. — Boston Medical and Surgi- 
they have access. — American Journal of the Med. cal Journal, March 28, 1861. 
Sciences, April, 1861. ... . . jV'., ,- , ,..■ 

' i It is unnecessary to si ve a detail oi the additions; 

It is, therefore, no disparagement to the many suffice it to say, that they are numerous and import- 
books upon physiology, most excellent in their day, ant, and such as will render the work still more 
to say that Dalton's is the only one that gives us the valuable and acceptable to the profession as a learn- 
Bcience as it was known to the best philosophers ed and original treatiseon this all-important branch 
throughout the world, at the beginning of the cur- | of medicine. All that was said in commendation 
rent year. It states in comprehensive but concise of the getting up of the first edition, and the superior 
diction, the facts established by experiment, or style of the illustrations, apply with equal force to 
other method of demonstration, and details, in an , this. No better work on physiology can be placed 
understandable manner, how it is done, but abstains in the hand of the srudent. — St. Louis Medical and 
from thediscussion of unsettled or theoretical prints. ' Surgical Journal, May, 1861. 

Herein it if unique; and these characteristics rm ! These additions, while testifying to the learning 
der it a text-book without a rival, for those who and ; ndustry of the au ,hor, render the hook exceed- 
desire to study physiological science as it is known ingly usefu , as tne most complete expose of a s«.-i- 
to its most successful cultivators. And it is physi- ence f which Dr. Dalton is doubtless the ablest 
ology thus presented that lies at the foundation of representative on this side of the Atlantic— Neu> 
correct pathological knowledge; and this in turn is ■ Orleans Med. Times, May, 1861. 
the basis of rational therapeutics ; so that patholo- , ,. ' .. . , 

gy, in fact, becomes of prime importance in the ! u A second edition of this deservedly popular wor" 
proper discharge of our everyday practical duties. ! having been called for in the 
— Cincinnati Lancet, May, 1861. 



rt space of two 
years," the author has supplied deficiencies, which 
existed in the former volume, and has thus more 
Dr. Dalton needs no word of praise from us. He ; completely fulfilled his design of presenting to the 
is universally recognized as among the fir6t, if not profession a reliable and precise text- book, and one 
the very fiist, of American plivsiologietsnow living, which we consider the best outline on the subject 
The first edition of his admirable work appeared but : of which it treats, in any language. — N. American 
two years since, and the advance of science, his Medico-Ckirurg. Review, May, 1861. 



DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. 
THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on 

the Nature and Treatment of Diseases, Materia Medicu, and Therapeutics, Diseases of Women 
and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 
3254 double-columned pages, strongly and handsomely bound, with raised bands. $15 00. 
*#* This work contains no less than lour hundred and eighteen distinct treatises, contributed by 

•ixty-eight distinguished physicians, rendering it a complete library of reference for the country 

practitioner. 
The most complete work on Practical Medicine | The editors are practitioners of established repu- 

•xtant; or, at least, in our language.— Buffalo j tation, and the list of contributors embraces many 

Medical and Surgical Journal. 



For reference, it is above all price to every prac- 
titioner.— Western Lancet. 

One of the most valuable medical publications of 
the day— aB a work of reference it is invaluable— 
Western Journal oj Medicine and Surgery. 

It has been to us, both as learner and teacher, a 
work for ready and frequent reference, one In which 
modem English medicine is exhibited in the most 
advantageous light. — Medical Examiner. 



of the most, eminent professors and teachers of Lon- 
don. Edinburgh, Dublin, and Glasgow. It is, in- 
deed, the great merit of this work that the principal 
articles have been furnished by practitioners who 
have not only devoted especial attention to the dis- 
eases about which they have written, but have 
also enjoyed opportunitiei for an extensive praeti- 
e.-il acquaintance With them and whose reputation 
Carriei the assurance of their competency justly to 
appreciate the opinions ol others, while it stamps 
their OWU doctrineswitl 1 high andjust authority. — 
ndl. 



American Medical Joumv 



DEWKKS'S COMPREHENSIVE SYSTEM OF I 
MIDWIFERY, illustrated by occasional cases 
«nd many engravings. Twelfth edition, wit h the I 
author's last improvements and corrections in 
one octavo volume, extra cloth, ol 600 pages 83 50. 

DEWEES'S TREATISE ON THE PHYSICAL 



AND MKDICAL TREATMENT OF CHILD 
REN. The hist edition. In one volume, octavo, 
extra cloth, 548 pages *3 80 
DEWEES'8 TREATISE ON THE DISEASES 
OF FEMALES. Tenth edition. In one volume, 
octavo extra cloth, 532 pages, with ptutcs. $3 00. 



12 



HENRY C. LEA'S MEDICAL 



DUNGLISON (ROBLEY), M.D., 

Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia 

ENLARGED AND REVISED EDITION OF 1865 — k Just Issued.) 

MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise 

Explanation ot the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, 
Therapeutics Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Den- 
tistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic 
Preparations; with the Accentuation and Etymology of the Terms, <md the French and other 
Synonymes; so as to constitute a French as well as English Medical Lexicon. Thoroughly 
revised and very greatly modified and augmented, in one very large and handsome royal 
octavo volume, of 1048 double-columned pages, in small type; strongly done up in extra cloth, 
$rj 00 ; leather, raised bands, $6 75 

Preface to the New Edition 
" The author has again been required to subject his Medical Lexicon to a thorough revision. 
The progress of Medical Science, and the consequent introduction of new subjects and terms, 
demanded this; and he has embraced the occasion to render more complete the etymology and 
accentuation of th« terms. On no previous revision has so much time and labor been expended by 
him. Some idea may be formed of this, from the fact, that although the page has been augmented 
in all its dimensions, not fewer than between sixty and seventy pages have been added. 

t; As the author has remarked on former occasions, it has ever been his ardent wish to make the 
work a satisfactory and desirable — if not indispensable — lexicon, in which the inquirer may search, 
without disappointment, for every term that has been legitimated in the nomenclature of the science; 
and he confidently presents this edition as having more claims on the attention of the practitioner 
and student than its predecessors. 

•'Once more the author gladly seizes the opportunity afforded him to express his grateful acknow- 
ledgments for the vast amount of favor which has been extended to the Dictionary." 
January, 1865. 
The object of the author from the outset has not been to make the work a mere lexicon or dic- 
tionary of terms, but to afford, under each a condensed view of its various medical relations, and 
thus to render the work an epitome of the existing condition of medical science. Starting with 
this view, the immense demand which has existed for the work has enabled him, in repeated re- 
visions, to augment its completeness and usefulness, until at length it has attained the position of 
a recognized and standard authority wherever the language is spoken. This has only been accom- 
plished by the earnest determination to bring each successive edition thoroughly on a level with 
the most advanced condition of contemporary medical science, and on no previous occasion has 
this demanded a more patient and laborious effort than in rendering the present edition fully equal 
to the wants of the student of the present day, and in no previous editions has the amount of new 
matter introduced been so large. While, therefore, the reader who merely desires a vocabulary 
explaining the terms in common use can satisfy himself with the smaller works, such as Hoblyn's, 
the student and practitioner who wish a work to which they can at all times refer with unfailing 
confidence tor all which it is the province of such a book to supply, must still, as heretofore, keep 
the latest edition of " Dunglison's Dictionary" within reach. 

The mechanical execution of this edition will be found greatly superior to that of previous im- 
pressions. By enlarging the size of the volume to a royal octavo, and by the employment of a small 
but clear type on extra fine paper, the additions have been incorporated without materially increas- 
ing the bulk of the volume, and the matter of two or three ordinary octavos has been compressed 
into the space of one not unhandy for consultation and reference. 
A few notices of the previous editions are subjoined. 



This work, the appearance of the fifteenth edition 
of which it has become our duty and pleasure to 
;>nnounce,is perhaps the most stupendous monument 
of labor and erudition in medical literature. One 
would hardly suppose after constant use of the pre- 
ceding editions, where we have never failed to find 
a sufficiently full explanation of every medical term, 
that in this edition " about six thousand subjects 
and terms have been added," with a careful revision 
and correction of the entire work. It is only neces- 
sary to announce the advent of this edition to make 
it occupy the place of the preceding one on the table 
of every medical man, as it is withoutdoubt the best 
and most comprehensive work of the kind which has 
ever appeared. — Buffalo Med.Journ., Jan. 1858. 

The work is a monument of patient research, 
skilful judgment, and vast physical labor, that will 
perpetuate the name of the author more effectually 
than any possible device of stone or metal. Dr. 
Dunglison deserves the thanks not only of the Ame- 
rican profession, but of the whole medical world.— 
North Am. Medico-Chir. Review, Jan. 1858. 

A Medical Dictionary better adapted for the wants 
of the profession than any other with which we are 
acquainted, and of a character which places it far 
above comparison and competition. — Am. Journ. 
Med. Sciences, Jan. 1858. 

We need only say, that the addition of 6,000 new 
terms, with their accompanying definitions, may be 
said to constitute a new work, by itself. We have 
examined the Dictionary attentively, and are most 
happy to pronounce it unrivalled of its kind. The 
erudition displayed, and the extraordinary industry 
winch must have been demanded, in its preparation 
and perfection, redound to the lasting credit of its 



author, and have furnished us with a volume indis- 
pensable at the present day, to all who would find 
themselves au niveau with the highest standards of 
medical information. — Boston Medical and Surgical 
Tournal,T>ec.3l, 1857. 

Good lexicons and encyclopedic works generally, 
are the most labor-saving contrivances which lite- 
rary men enjoy ; and the labor which is required to 
produce them in the perfect manner of this example 
s something appalling to contemplate. The author 
tells us in ins preface that lie has added about six 
thousand terms and subjects to this edition, which, 
before, was considered universally as the best work 
of the kind in any language. — Silliman's Journal, 
March, 1858. 

A complete and thorough exponent of medical 
terminology, without rival or possibility of rivalry. 
— Nashville Journ. of Med. and Surg., Jan. 1858. 

It is universally acknowledged, we believe, that 
this work is incomparably the best and most com- 
plete Medical Lexicon in the English language. 
Comment and commendation are unnecessary, as no 
one at the present day thinks of purchasing any other 
Medical Dietionarj than this. — St. Louis Med. and 
Surg. Journ., Jan 1S58. 

It is the foundation stone of a good medical libra- 
ry, and should always be included in the first list of 
books purchased by the medical student. — Am. Med. . 
Monthly, Jan. 1858. 

It is scarcely necessary to remark that any medi- 
cal library wanting a copy of Dunglison's Lexicon 
must be imperfect. — Cin. Lancet, Jan. 1858. 

Thepresentedition we may safely say has no equal 
in the world.— Peninsular Med. Journal Jan. 1858. 



AND SCIENTIFIC PUBLICATIONS. 



13 



DUNGLISON (ROSLEYI, M.D., 
Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 

HUMAN PHYSIOLOG-Y. Eighth edition. Thoroughly revised and exten- 
sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and 
handsomely printed octavo volumes, extra cloth, of about 1500 pages. $7 00. 

In revising this work for its eighth appearance, the author has spared no labor to render it worthy 
a continuance of the very great favor which has been extended to it by the profession. The whole 
contents have been rearranged, and to a great extent remodelled ; the investigations which of late 
years have been so numerous and so important, have been carefully examined and incorporated, 
and the work in every respect has been brought up to a level with the present state of the subject. 
The object of the author has been to render it a concise but comprehensive treatise, containing the 
whole body of physiological science, to which the student and man of science can at all times refer 
with the certainty of finding whatever they are in search of, fully presented in all its aspects ; and 
on no former edition has the author bestowed more labor to secure this result. 

We believe that it can truly be said, no more com- 
plete repertory of facts upon the subject treated, 
can anywhere be found. The author has, moreover, 
tl.at enviable tact at description and that facility 
and ease of expression which render him peculiarly 
acceptable to the casual, or the studious reader. 
This faculty, so requisite in setting forth many 
graver and less attractive subjects, lends additional 
charms to one always fascinating.— Boston Med. 
and Surg. Journal. 

The most complete and satisfactory system of 
Physiology in the English language. — Amer.Med 
Journal . 



j The best work of the kind in the English lan- 
guage. — Silliman's Journal. 

The present edition the author has made a perfect 
mirror of the science as it is at the present hour. 
As a work upon physiology proper, the science of 
the functions performedby the body, the student will 
find it all he wishes. — Nashville Journ. of Med. 

That he has succeeded, most admirably succeeded 
in his purpose, is apparent from the appearance of 
an eighth edition. It is now the great encyclopasdia 
on the subject, and worthy of a place in every phy- 
sician's library. — Western Lancet. 



BV THE SAME AUTHOR. 

GENERAL THERAPEUTICS AND MATERIA MEDIC A; adapted for a 

Medical Text-book. With Indexes of Remedies and of Diseases and their Hemedies. Sixth 
Edition, revised and improved. With one hundred and ninety-three illustrations. In two large 
and handsomely printed octavo vols., extra cloth, of about 1100 pages. $6 50. 

In announcing a new edition of Dr. Dunglison's i The work will, we have little doubt, be bought 
General Therapeutics and Materia Medica, we have [ and read by the majority of medical students: its 



no words of commendation to bestow upon a work 
whose merits have been heretofore so often and so 
justly extolled. It must not be supposed, however, 
that the present is a mere reprint of the previous 
edition: the character of the author for laborious 
research, judicious analysis, and clearness of ex- 
pression, is fully sustained by the numerous addi- 
tions he has made to the work, and the careful re- 
vision to which he has subjected the whole.— N. A. 
Mtdico-Chir. Review, Jan. 1858. 



ze, arrangement, and reliability recommend it to 
all; no one, we venture to predict, will study it 
without profit, and there are few to whom it will 
not be in some measure useful as a work of refer- 
ence. The young practitioner, more especially, will 
find the copious indexes appended to this edhion of 
great assistance in the selection and preparation of 
suitable formulas. — Charleston Med. Journ. and Re- 
view, Jan. 1858. 



BV THE SAME AUTHOR. 

NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND 

ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo 
volume, extra cloth, of 770 pages. $4 GO. 



One of the most useful of the author's works. — 
Southern Medical and Surgical Journal. 

This elaborate and useful volume should be 
found in every medical library, for as a book of re- 
ference, for physicians, it is unsurpassed by any 
other work in existence, and the double index for 
diseases and for remedies, will be found greatly to 
•nhance its value. — Ntie York Med. Gazettt. 



The great learning of the author, and his remark- 
able industry in pushing his researches into every 
source whence information is derivable, have enabled 
him to throw together an extensive mass of facts 
and statements, accompanied by full reference to 
authorities; which last feature renders the work 
practically valuable to investigators who desire to 
examine the original papers.— The American Journal 
of Pharmacy. 



ELLIS (BENJAMIN). M.D. 
THE MEDICAL FORMULARY : being a Collection of Prescriptions, derived 

from the writings and practice of many of the most eminent physicians of America and Europe. 
Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added 
an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Eleventh edition, 
carefully revised and much extended by Robert P. Thomas, M. D., Professor of Materia Me- 
dica m the Philadelphia College of Pharmacy. In one volume, 8vo., of about 300 pages. $3 00. 
(Just Issued.) 

On DO previous edilion of this work has there been so complete and thorough a revision. The 
extensive changes in the new United States Pharmacopoeia have sessitated corresponding alter- 
ations in the Formulary, to conform to that national Btandard, while the progress made in the 
materia medica and the arts of prescribing and dispensing during the last ten years have been care- 
fully noted and incorporated throughout. It is therefore presented as not only worthy a continuance 
of the favor so long enjoyed, but us more valuable lhan ever to the practitioner and pharmaceutist. 
Those wlio possess previous editions will find the additional matter of sullicieut importance to 
warrant their adding the present to their libraries. 



14 



HENRY C. LEA'S MEDICAL 



ERICHSEN (JOHN), 

Professor of Surgery in University College, London, *c. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgioax 

Injuries. Diseases, and Operations. New and improved American, from the second enlarged 

and carefully revised London edition. Illustrated with over four hundred engravings on wood. 

In one large and handsome octavo volume, of one thousand closely printed pages, extra clotb, 

$6 00. 

The very distinguished favor with which this work has been received on both sides of the Atlan- 
tic has stimulated the author to render it even more worthy of the position which it has so rapidly 
attained as a standard authority. Every portion has been carefully revised, numerous additions 
have been made, and the most watchful care has been exercised to render it a complete exponent 
of the most advanced condition of surgical science. In this manner the work has been enlarged by 
about a hundred pages, while the series of engravings has been increased by more than a hundred, 
rendering it one of the most thoroughly illustrated volumes before the profession. The additions of 
the author having rendered unnecessary most of the notes of the former American editor, but little 
has been added in this country; some lew notes and occasional illustrations have, however, been 
introduced to elucidate American modes of practice. 

excellent contribution to surgery, as probably tha 



It is, in our humble judgment, decidedly the best 
book of the kind in the English language. Strange 
that just such books are notoftener produced by pub- 
lic teachers of surgery in this country and Great 
Britain Indeed, ills a matter of great astonishment 
but no less true than astonishing, that of the many 
works on surgery republished in this country within 
the last fifteen or twenty years as text-books for 
medical students, Ihis is the only one that even ap- 
proximates to the fulfilment of the peculiar wains of 
young men justentennguponthe study ofthisbrancli 
of the profession. — Western Jour .of Med. am) Surgery. 

Its value is greatly enhanced by a very copious 
well-arranged index. We regard this as one of the 
most valuable contributions to modern surgery. To 
one entering his novitiate of practice, we regard it 
the most serviceable guide which he can cocsurt. He 
will find a fulness of detail leading him through everv 
step of the operation, and not deserting him until the 
final issue of the case is decided. — Seihoscope. 

Embracing, as will be perceived, the whole surgi 
cal domain, and each division of itself almost com 
plete and perfect, each chapterfull and explicit, eacl 
subject faithfully exhibited, we can only express ou 
estimate of it in the aggregate. We consider it at 



best single volume now extant on the subject, and 
with great pleasure we add it to our text-books. — 
Nashville Journal of Medicine and Surgery. 

Prof. Erichsen's work, for its size, has not been 
surpassed; his nine hundred and eight pages, pro- 
fusely illustrated, are rich in physiological, patholo- 
gical, and operative suggestions, doctrines, details, 
and processes; and will prove a reliable resource 
for information, both to physician and surgeon, in the 
hour of peril. — N. 0. Med. and Surg. Journal. 

We may say, after a careful perusal of some of 
the chapters, and a more hasty examination of the 
remainder, that it must raise the character of the 
author, and reflect great credit upon the college lo 
which he is professor, and we can cordially recom- 
mend it as a work of reference both to students 
and practitioners. — Med. Times and Gazette. 

We do not hesitate to say that the volume before 
us gives a very admirable practical view of the sci- 
ence and art ot Surgery of the present day, and we 
have no doubt that it will be highly valued as a 
surgical guide as well by the surgeon as by the 
student of surgery. — Edinburgh Med. and Swg. 
Journal. 



FISKE FUND PRIZE ESSAYS— THE EF- I 
FECTS OF CLIMATE ON TUBERCULOUS 
DISEASE. By Edwin Lee, M.R.C.S , -London, j 
and THE INFLUENCE OF PREGNANCY ON I 
THE DEVELOPMENT OF TUBERCLES By 



Edward Warren, M. D., of Edenton,N. C. To- 
gether in one neat 8vo. volume, extra cloth. $1 00. 
FRICK ON RENAL AFFECTIONS; their Diag- 
nosis and Pathology. With illustrations. Ooe 
volume, royal 12mo., extra cloth. 75 cents. 



FERGUSSON (WILLIAM), F. R. S., 

Professor of Surgery in King's College, London, &c. 

A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third 

and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 
pages, with 393 handsome illustrations, leather. $4 CO. 



FOWNES (GEORGE), PH. D., Sec. 
A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. 

With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one 

large royal 12mo. volume, of 600 pages, extra cloth, $2 00. 

The death of the author having placed the editorial care of this work in the practised hands ol 
Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience 
could suggest to keep it on a level with the rapid advance of chemical science. The additions 
reqnisite'to this purpose have Hecesj-itated an enlargement of the page, notwithstanding which the 
work has been increased by about fifty pages. At the same time every care has been used to 
maintain its distinctive character as a condensed manual for the student, divested of all unnecessary 
detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- 
ment of Organic Chemistry, which has made such rapid progress within the last few years, but 
yet equal attention has been bestowed on the other branches of the subject — Chemical Physics and 
Inorganic Chemistry — to present all investigations and discoveries of importance, and to keep up 
the reputation of the volume as a complete manual of the whole science, admirably adapted for the 
learner. By the use of a small but exceedingly clear type the matter of a large octavo is compressed 
within the convenient and portable limits of a moderate sized duodecimo, and at the very low price 
affixed, it is offered as one of the cheapest volumes before the profession. 



Dr. Fownes' excellent work has been universally 
recognized everywhere in Mis own and tbiseounlry, 
an the best elementary treatise on chemistry in the 
English tongue, and is very generally adopted, we 
believe, as the standard text-book in all cur colleges, 
both literary and scientific— Charleston Med Journ. 
and Review 



The work of Dr. Fownes has long been before 
the public, and its merits have been fully appreci- 
ated as the best text-book on chemistry now in 
existence. We do not, of course, place it in n rank 
superior to the works of Brande, Graham, Turner, 
Gregory, or Gmelin, but we say that, as a work 
for students, it is preferable to any of them. — La* 
don Journal of M<idiciv£. 



AND SCIENTIFIC PUBLICATIONS. 



IS 



FLINT (AUSTIN), M . D., 

Professor of the Principles and Practice of Medicine in Bellevue Hosp. Med. College, New York. 
Now Ready, 1866. 

THE PRINCIPLES AND PRACTICE OF MEDICINE. For the use of 

Practitioners and Students. In one large and handsome octavo volume of over 850 closely 

printed pages, leather, raised bands, $7; handsome extra cloth, $6. 

The want has for some time been felt in this country of a volume which, within a moderate 
compass, should give a dear and connected view of general and special pathology and therapeutics 
in their most modern aspect. Recent researches have modified many opinions which vere formerly 
universally received on important points boih of theory and practice, and the«e changes nave per- 
haps as yet scarcely received the attention due to them in the works accessible to the profession. 
The author's reputation as a teacher is a guarantee that the present volume wilt be fully up to the 
most advanced state of the science of the day, while his long and varied experience as a Dracti- 
tioner will insure (hat in all practical details his work will be a sound and trustworthy guide. 

by the' same author. {Preparing.) 

PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- 
ING THE RESPIRATORY ORGANS. Second edition. In one large and handsome octavo 



volume, extia cloth. 



BY THE SAME AUTHOR. 



A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND 

TREATMENT OF DISEASES OF THE HEART. ' In one neat octavo volume, of about 
500 pages, extra cloth. $3 50. 



We do no* know that Dr. Flint has written any- 
thing which is not first rate ; but this, his latest con- 
tribution to medical literature, in our opinion, sur- 
passes all the others. The work is most comprehen- 
sive in its scope, and most sound in the views it enun- 
ciates. The descriptions are clear and methodical; 
the statements are substantiated by facts, and are 



made with such simplicity and sincerity, that with- 
out them they would carry conviction. The style 
is admirably clear, direct, and free from dryness. 
With Dr. Walshe's excellent treatise before us, we 
have no hesitation in saying that Dr. Flint's book is 
the best, work on the heart in the English language. 
—Boston Med. and Surg. Journal. 



GRAHAM (THOMAS), F. R. S. 
THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- 

tions of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert 
Bridges, M. D. Complete in one large and handsome octavo volume, ol over S00 very large 
pages, with two hundred and thirty-two wood-cuts, extra cloth. $5 50. 

** # Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be 
had separate, cloth backs and paper sides. Price $3 00. 

From Prof. E. N. Horsford, Harvard College. j afford to be without this edition of Prof. Graham's 

It has, in its earlier and less perfect editions, been ] Elements.— Silliman's Journal, March, 1858. 

familiar to me, and the excellence of its plan and i From Prof. Wolcott G-ibbs, N. Y. Free Academy 

the clearness and completeness of its discussions, The work is an admirable one in aU resp ects, and 

have long been my admiration. I itB republication here cannot fail to exert a positive 

No reader of English works on this science can , intluenceupon theprogressofsciencem this country. 



GRIFFITH (ROBERT E.), M. D., &c 

A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- 
ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- 
tists. Skcond Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, 
M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and 
handsome octavo volume, extra cloth, of 650 pages, double columns. $4 00. 

It was a work requiring much perseverance, and vision and ample additions of Dr Thomas, and is 
wli'ii published was looked upon as by far the best I now, we believe, one of the mosi con.plete works 
work of its kind that hud issued from the American j of its kind in any language. The additions amount 
press. Prof. Thomas has certainly "improved," as to aboutsevenly pages, and no effort lias been spared 
well as added lothis Formulary, nnd has rendered it I to include in them all the recent improvements. A 
additionally deserving of the confidence of pliarma- work of ibis kind appears to us indispensable to the 



physician, and there is none we can more cordiallv 
recommend — N. Y. Journal of Medicin*. 



eeutixlsand physicians. — Am. Journal of Pharmacy . 

We are happy to announce a new and improved 
edition of this, one of the most valuable and useful 

works that have emanated from an American pen. Pre-eminent among the best and most useful eom- 

K would do credit to any country, and will be found pUationaof the present day will be found the work 

Of daily DBOfulness lo practitioners of medieine; H is ''efore us, winch can have been produced only at a 

better adapted to their purposes than the dispeusalo- very great, cost of thought Bad labor A short de- 

riea.-Southern MM. and Sur K . Journal. ■enptlOBWlll suff.ee to show that we do not put too 

, high an estimate OB this work Wc are not eoeni- 

ItiB one ofthe most uiefulbooka a country practl- \ x ^ t <* the existence of a parallel work, its value 

tio.-resnnossiblvhave.— Medical ChromcU. wlM be apparent to our readers from tne sketC '. 

i- a work of six hundred and fifty- one pages its contents above given. We strongly recommend 



embracing all on the subject of preparing unci ailnii 
liaterina medicines that can be desired by ihc physi 
eiu.i and pharmaceutist.— Wetttm Lancet 

"iinlof useful, even -day matter, for aprac 
ncing physician, is really immense.— Boston Med 
and Surt(. Journal. 
This edition has been greatl) improved by the re- 



it to all who are engaged either ill practical medi- 
cine, or moreexclusively with its literature. — Lond. 
Med. Gazette. 

A very useful work, and a most complete compen- 
diii.il on the Subject Of materia medica. We know 
of DO work in our language, or any other, so com- 
prehensive in all its details.— London Lancet. 



HENRY C. LEA'S MEDICAL 



GROSS (SAMUEL D.), M. D., 

Professor of Surgery in the Jefferson Medical College of Philadelphia, 4c. 

Enlarged Edition. 

A SYSTEM OF SURGERY : Pathological, Diagnostic, Therapeutic, aDd Opera- 
tive. Illustrated by over Thirteen Hundred Engravings. Third edition, much enlarged and 
can-fully revised. In two large and beautifully printed royal octavo volumes, of 2200 pages ; 
leather. $15 00. {Just Issued.) 

The exhaustion within five years of two large editions of so elaborate and comprehensive 
a work as this is the best evidence that the author was not mistaken in his estimate of the 
want which existed of a complete American System of Surgery, presenting the science in all Us 
necessary details and in all its branches. That he has succeeded in the attempt to supply this want 
is shown not only by the rapid sale of the work, but also by the very favorable manner in which it 
has been received by the organs of the profession in this country and in Europe, and by the fact that 
a translation is now preparing in Holland — a mark of appreciation not often bestowed on any scien- 
tific work so extended in size. 

The author has not been insensible to the kindness thus bestowed upon his labors, and in revising 
the work for a third edition he has spared no pains to render it worthy of the favor with which it 
has been received. Every portion has been subjected to close examination and revision ; any defi- 
ciencies apparent have been supplied, and the results of recent progress in the science and art of 
surgery have been everywhere introduced; while the series of illustrations has been still further 
enlarged, rendering it one of the most thoroughly illustrated works ever laid before the profession. 
To accommodate these very extensive additions, the form of the work has been altered to a royal 
octavo, so that notwithstanding the increase in the matter and value of the book, its size wi.l be found 
more convenient than before. Every care has been taken in the printing to render the typographical 
execution unexceptionable, and it is confidently expected to prove a work in every way worthy of 
a place in even the most limited library of the practitioner or student. 

Has Dr. Gross satisfactorily fulfilled this object? 
A careful perusal of his volumes enables us to give 
an answer in the affirmative. Not only lias he given 
to the reader an elaborate and well-written account 
of his own vast experience, but he has not failed to 



embody in his pages the opinions and practice of 
lrgeons in this and other countries of Europe. The 



confess we were by no means prepared for the work 
which is before us — the most complete treatise upon 
surgery ever published, either in this or any other 
country, and we might, perhaps, safely say, the 
most original. There is no subject belonging pro- 
perly to surgery which has not received from the 
th'oi a due share of attention. Dr. Gross has sup- 



result has been a work of such completeness, that it plied a want in surgical literature which has long 
has no superior in the systematic treatises on sur- | been felt by practitioners; he has furnished us with 
gery which have emanated from English or Conti- j a complete practical treatise upon surgery in all its 
nental authors. It has been justly objected that departments. As Americans, we are proud of the 
these have been far from complete in many essential j achievement; as surgeons, we are most sincerely 
particulars, many of them having been deficient in , thankful to him for his extraord nary labors in our 
some of the most important points which should behalf. — iV. Y. Review and Buffalo Med Journal. 
characterize such works Some of them have been | The t mcrit of the work bg stated as 

elaborate-too elnborate-wnh respect to certain | followa> it presents surgical science as it exists 
diseases, while they have merely glanced at, or at the , ategt dat whh a f, jtg improvernents . and 



it, or 
given an unsatisfactory account of, others equally 



mportant to the surgeon. Dr. Gross has avoided 
thiserror, and has produced the most complete work 
that has yet issued from the press on the science and 
practice of surgery. It is not, strictly speaking, a 
Dictionary of Surgery, but it gives to the reader all 
the information that he may require for his treatment 
of surgical diseases. Having said so much, it might 
appear superfluous to add another wurd ; but it is 
only due to Dr. Gross to state that he has embraced 
the opportunity of transferring to his pages a vast 
number of engravings from English and other au- 
tnors, illustrative ot the pathology and treatment of 
surgical diseases. To these are added several h un- 
dred original wood-cnts. The work altogether com- 
mends itself to the attention of British surgeons, 
from whom it cannot fail to meet with extensive 
patronage. — London Lancet, Sept. 1, 1860. 

Of Dr. Gross's treatise on Surgery we can say 
no more than that it is the most elaborate and com- 
plete work on this branch of the healing art which 
has ever been published in any country. A sys- 
tematic work, it admits of no analytical review; 
but, did our space permit, we should gladly give 
some extracts from it, to enable our readers to judge 
of the classical style of the author, and the exhaust- 
ing way in which each subject is treated.— Dublin 
Quarterly Journal of Med. Science. 

The work is so superior to its predecessors in 
mutter and extent, as well as in illustrations and 
style of publication, that we can honestly recom- 
mend it as the best work of the kind to be taken 
home by the young practitioner. — Am. Med.Joum. 

With pleasure we record the completion of this 
long-anticipated work. The reputation which the 
author has for many years sustained, both us a sur- 
geon and as a writer, had prepared us to expect a 
treatise of great excellence and originality ; but we 



t discusses every topic in due proportion. No- 
thing is omitted, nothing is in excess.— Chicago 
Med. Examiner, May, 1860. 

We cannot close this brief notice of Dr. Gross's 
most valuable and excellent compendium of Sur- 
gery without again drawing attention to it, as we 
aid in our notice of his first edition, as an evidence 
of the progress our American brethren are making 
towards establishing a literature of their own. — 
Dublin Quarterly Journal, Feb. 1863. 

It has been characterized by the representative 
press and by individual surgeons of the highest 
eminence, both at home and abroad, as " the best 
systematic work on surgery ever published in the 
English language;" and that the profession at 
large have given substantial proofs of their agree- 
ment to this verdict, is sufficiently evident from the 
fact that, translations into European languages have 
been called for, and that so shortly after its first 
appearance, and at a time most unfavorable to 
literary "enterprise," the Philadelphia publishers 
have found it pay to issue a " second edition, much 
enlarged and carefully revised."— American Med. 
Monthly, May, 1862 

We are much gratified to be able to announce a 
new edition of this Cyclopaedia of Surgery. Con- 
sidering the large size of the work and its expen- 
siveness, the extremely rapid 3ale and exhaustion 
of an entire edition, not only proves the value of 
the work, and its adaptation to the wants of the 
profession, but it speaks well for the intelligence 
of American surgeons. — American Medical Times, 
May, 1868. 

A valuable and even necessary addition to every 
surgical library.— Chicago Med. Journ., Dec. 1859. 

A system of surgery which we think unrivalled 
in our language. — British American Journal. 



BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- 

SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. $2 75. 



AND SCIENTIFIC PUBLICATIONS. 



17 



GROSS (SAMUEL D.), M. D. 
Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. 

ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly 

revised and greatly improved. In one large and very handsome octavo volume, with about three 

hundred and fifty beautiful illustrations, of which a large number are from original drawings, 

extra cloth. $4 00. 

The very rapid advances in the Science of Pathological Anatomy during the last few years have 
rendered essential a thorough modification of this work, with a view of making it a correct expo- 
nent of the present state of the subject. The very careful manner in which this task has been 
executed, and the amount of alteration which it has undergone, have enabled the author to say that 
" with the many changes and improvements now introduced, the work may be regarded almost as 
a new treatise," while the efforts of the author have been seconded as regards the mechanical 
execution of the volume, rendering it one of the handsomest productions of the American press. 



BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND 

MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND 
THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- 
four illustrations. In one large and very handsome octavo volume, of over nine hundred pages, 
extra cloth, $4 00. 

Philosophical in its design, methodical in its ar- 1 agree with us, that there is no work in the English 
rangement, ample and sound in its practical details, language which can make any just pretensions to 
it may in truth be said to leave scarcely anything to be its equal. — N. Y. Journal of Medicine. 



be desired on so important a subject.— Boston Med. 
mnd Surg Journal. 

Whoever will peruse the vast amount of valuable 
practical information it contains, will, we think, 



A volume replete with truths and principles of the 
utmost value in the investigation of these diseases. — 
American Medical Journal. 



GRAY (HENRY), F. R. S., 

Lecturer on Anatomy at St. George's Hospital, London, &c. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. 

Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly 
by the Author and Dr. Carter. Second American, from the second revised and improved 
London edition. In one magnificent imperial octavo volume, of over 800 pages, with 3SS large 
and elaborate engravings on wood. Price in extra cloth, $6 00; leather, raised bands, $7 00. 
The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe- 
cution have been found to present superior practical advantages in facilitating the study of Anato- 
my In presenting it to the profession a second time, the author has availed himself of the oppor- 
tunity to supply any deficiencies which experience in its use had shown to exist, and to correct 
any errors of detail, to which the first edition of a scientific work on so extensive and complicated 
a science is liable. These improvements have resulted in some increase in the size of the volume, 
while twenty-six new wood-cuts have been added to the beautiful series of illustrations which 
form bo distinctive a feature of the work. The American edition has been passed through the press 
under the supervision of a competent professional man, who has taken every care to render it in 
all re-peets accurate, and it is now presented, without any increase of price, as fitted to maintain 
and extend the popularity which it has everywhere acquired. 



Willi little trouble, the busy practitioner whose 
knowledge of anatomy may have become obscn red by 
want of practice, may now resuscitate his former 
anatomical lore, and be ready for any emergency. 
It is to this class of individuals, and not to the stu- 
dent alone, that this work will ultimately tend to 
be of most incalculable advantage, and we feel sat- 
isfied that, the library of the medical man will soon 
be considered incomplete in which a copy of this 
work does not exist.- Madras Quarterly Journal 
of Med. Science, July, 1861. 

This edition is much improved and enlarged, and 
contains several new illustrations by Dr. Weslma- 
cott. The volume is a complete companion to the. 
dissecting-room, and saves the necessity of the stu 
dent possessing a variety of" Manuals."— The Lon 
don Lancet, Feb. 9, 1661. 



work of Mr. Gray to the attention of the medical 
profession, feeling certain ttiat it should be regarded 
as one of the most valuable contributions ever made 
to educational literature. — N. Y. Monthly Review. 
Dec. 1859. 

In this view, we regard the work of Mr. Gray as 
far better adapted to the wants of the profession, 
and especially of the student, than any treatise on 
matomy yet published in this country. It is destined, 
we believe, CO supersede nil others, both as a manual 
.)f dissections, and a standard of reference to the 
student of general or relative anatomy. — N. Y. 
Journal of Medicine, Nov. 1859. 



In our judgment, the mode of illustration adopted 
in the present, volume cannot but present many ad- 
vantages to I he studenl of anatomy. To I lie zealous 

The work before us is one entitled to the highest disciple of Vesalius. earnestly desirous of real im- 
praise, and we accordingly welcome it as a vain- provement, the book will certainly be of immense 
iddition to medical literature. Intermediate value; but, at the same time, we must also confess 



in fulness of detail between the treatises of S.iar- 
pey and of Wilson, its characteristic merit, lies in 
the number and excellence of the engravings it 
contains. Most of these are original, of much 
lureer limn ordinary size, and admirably executed 



that to those simply desirous of "cramming" it 
will be an undoubted godsend. The peculiar value 
of Mr. Gray's mode of illustration is nowhere mote 
markedly evident than in the chapter on osteology, 
ind especially in those portions which treat of the 



The various parts are also lettered after the plan j bones of the head and of their development. The 
adopted in Holden's Osteology. It would be difli- J study of these parlB is thus made one of comparative 
cult to over-estimate the advantages offered by this ease, if not of positive pleasure: and those bugbears 



illustration. 

(vessels, and ner 
figured, and marked with their 



mode of piclori 
muscles, bloodi 



a gen 

Ion 



nes, ligaments, 
;s are each in turn 
ppropriate names ; 
rehend, at s glance, 

, or ul any 

rate, acquired only by prolonged and irksome ap- 
plication. In conclusion, we heartily commend the 



thus enabling the studenl ti 

what would otherwise often be ignored 



of the student, the temporal and sphenoid bones, are 
shorn of half their terrors. It is, in our estimation, 
an admirable and complete text-book for the student, 
and a useful work of reference for the practitioner ; 
its pictorial character forming a novel element, to 
which we have already sufficiently alluded. — Am. 
Journ. Med. Sci., July, 1859. 



18 



HENRY C. LEA'S MEDICAL 



GIBSON'S INSTITUTES AND PRACTICE OF 
SURGERY. Eighth edition, improved and at- 
tend. With thirty-four plates. In two handsome 
octavo volumes, containing about 1,000 pages, 
leather, raised band i. $6 50 

GARDNER'S MEDICAL CHEMISTRY, for the 
use of Students and the Profession. In one royal 
12m o. vol., clof.h,pp. 396, with wood-cuts. SI. 

GLUGE'S ATLAS OF PATHOLOGICAL HIS- 
TOLOGY Translated, with Notes and Addi- 
tions by Joseph Leidy, M. D. In one volume. 
very large imperial quarto, extra cloth, with 320 
copper- plate figures, plain and colored, $4 00. 

HUGHES' INTRODUCTION TO THE PRAC- 



TICE OF AUSCULTATION AND OTHER 
MODES OF PHYSICAL DIAGNOSIS. IN DIS- 
EASES OF THE LUNGS AND HEART. Se- 
cond edition 1 vol. royal 12mo., ex. cloth, pp. 
304. $1 25. 

HOLLAND'S MEDICAL NOTES AND RE- 
FLECTIONS. From the third London edition. 
In one handsome octavo volume, extra cloth. 
S3 50. 

HORNER'S SPF.CIAL ANATOMV AND HIS- 
TOLOGY. Eighth edition. Extensively revised 
and modified, in two large octavo volumes, ex- 
tra cloth, of more than 1000 pages, with over 309 
illustrations. $6 00. 



HILLIER (THOMAS), M.D., 

Physician to the Skin Department of University College Hospital ; Physician to the Hospital for Sick 

Children, &c. &c. 

HANDBOOK OF SKIN DISEASES, FOR STUDENTS AND PRACTI- 
TIONERS. In one neat royal l'2mo. volume, of about 300 pages, with two plates; extra cloth, 
price $2 25. (Lately published ) 

From the Author's Preface. 
<• My object has been to furnish to students and practitioners a trustworthy, practical, and com- 
pendious treatise, which shall comprise the greater part of what has long been known of cutaneous 
diseases, and of what ha* been more recently brought lo light by English, French, and German 
deimaio'ogists, as well as to embody the most important results of my own experience in reference 
to these diseases " 

The author's position both as a lecturer, writer, and practitioner in this department of medicine, 
is a guarantee of his ability to accomplish his object in presenting a condensed and convenient 
manual, which shall comprise all that the general practitioner requires for his guidance. 

A text book well adapted to the student, and the information contained in it shows the author to be au 
niveau with the scientific medicine of the day.— London Lancet, Feb 25, 1865. 

HAMILTON (FRANK H.), M. D., 

Professor of Surgery in the Long Island College Hospital. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. 

Second edition, revised and improved. In one large and handsome octavo volume, of over 750 

pages, with nearly 300 illustrations, extra cloth, 85 25. 

The early demand for a new edition of this work shows that it has been successful in securing 
the confidence of the profession as a standard authority for consultation and reference on its import- 
ant and difficult subject. In again passing it through the press, the author has taken the opportu- 
nity to revise it carefully, and introduce whatever improvements have been suggested by further 
experience and observation. An additional chapter on Gun-shot Fractures will be found to adapt 
it still more fully to the exigencies of the time. 



Among the many good workers at surgery of whom 
America may now boast not the least is Frank Hast- 
ings Hamilton; and the volume before us is (we say 
it with a pang of wounded patriotism) the best and 
handiest book on the subject in the Erglish lan- 
gunge. It is in vain to attempt a review of it; 
nearly as vain to seek for any sins, either of com- 
mission or omission. We have seen no work on 
practical surgery which we would sooner recom- 



aflections. One great and valuable feature in the 
work before us is the fact that it comprises all the 
improvements introduced into the practice of both 
English and American surgery, and though far from 
omitting mention of our continental neighbors, the 
author by no means encourages the notion— but too 
prevalent in some quarters— that nothing is good 
unless imported from France or Germany. The 
latter half of the work is devoted to the considera- 



mend to our brother surgeons, especially those of tion of the various dislocations and their appropri- 
" the services," or those whose practice lies in dis- i ate treatment, and its merit is fully equal to that of 
tricts where a man has necessarily to rely on his the preceding portion. — The London Lancet,Ma.y 5, 
own unaided resources. The practitioner will find I860. 

in it directions for nearly every possible Resident, It ig emphatically the book upon the subjects of 
easily found and comprehended; and much pleasant which it tre ats, and we cannot doubt that it will 
readme for him to muse over in the after conndera- „„„„„„,, so to he for an inde nnite period of time, 
tionothiscases.— Edinburgh Med. Journ Feb.lSOl. ; When we say, however, that we believe it will at 
This is a valuable contribution to the surgery of | once take its place as the best book for consultation 
most important affections, and is the more welcome, , by the practitioner; and that it will form the most 
inasmuch as at the present time we do not possess i complete, available, and reliable guide in emergen- 
a single complete treatise on Fractures and Dislo- j cies of every nature connected with itssubjects; and 
cations in the English language. It has remained for also that the student of surgery may make it his text- 
our American brother to produce a complete treatise book with entire confidence, and with pleasure also, 
upon the subject, and bring together in a convenient | from its agreeable and easy style — we think our own 
form those alterations and improvements that, have j opinion may be gathered as to its value. — Boston 
been made from time to time in the treatment of these | Medical and Surgical Journal, March 1, 1860. 



HODGE (HUGH L.), M. D., 
Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, <fcc. 

ON DISEASES PECULIAR TO WOMEN, iDcludino; Displacements of the 

Uterus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 
pages, extra cloth. $3 75. 



This contribution towards the elucidation of the 
pathology and treatment of some of the diseases 
peculiar to women, cannot fail to meet with a favor 
able reception from the medical profession. The 
Character of the particular maladies of which the 
work before us treats; their frequency, variety, and 
obscuiity : the amount of malaise and even of actual 
suffering by which they are invariably attended; 
their obstinacy, the difficulty with which they are 
overcome, and their disposition again and again to 

The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. 



recur— these, taken in connection with the entire 
competency of the author to render a correct ac- 
count of their nature, their causes, and their appro- 
priate management — his ample experience, his ma- 
tured judgment, and his perfect conscientiousness — 
invest this publication with an interest and value to 
which few of the medical treatises of a recent <<ate 
can lay a stronger, if, perchance, an equal claim. — 
Am. Journ. Med. Sciences, Jan. 1861. 



AND SCIENTIFIC PUBLICATIONS. 19 

HODGE (HUGH L.), M. D., 
Late Professor of Midwifery, &c, in the University of Pennsylvania. 

PRINCIPLES AND PRACTICE OF OBSTETRICS. In one large quarto 

volume of O'/er 550 pages, with one hundred and fifty-eight figures on thirty two beautifully exe- 
cuted lithographic plates, and numerous wood-cuts in the text. $14 00. {Just Issued.) 
This work, embodying the results of an extensive practice for more than forty years, cannot fail 
to prove of the utmost value to all who are engaged in this department of medicine. The author's 
position as one of the highest authorities on the subject in this country is well known, and the fruit 
of his ripe experience and long observation, carefully matured and elaborated, must serve as an 
invaluable text-book for the student and an unfailing counsel for the practitioner in the emergencies 
which so frequently arise in obstetric practice. 

The illustrations form a novel feature in the work. The lithographic plates are all original, 
and to insure their absolute accuracy they have all been copied from photographs taken expressly 
for the purpose. In ordinary obstetrical plates, the positions of the fetus are represented by dia- 
grams or sections of the patient, which are of course purely imaginary, and their correctness is 
scarcely more than a matter of chance with the artist. Their beauty as pictures is thereby increased 
without corresponding utility to the student, as in practice he must for the most part depend for his 
diagnosis upon the relative positions of the foetal skull and the pelvic bones of the mother. It is, 
therefore, desirable that the points upon which he is in future to rely, should form the basis of his 
instruction, and consequently in the preparation of these illustrations the skeleton has alone been 
u«ed. and the aid of photography invoked, by which a series of representations has been secured of 
the strictest and most rigid accuracy. It is easy to recognize the value thus added to the very full 
detai's on the subject of the Mechanism of Labour with which the work abounds 

It may be added that no pains or expense have been spared to render the mechanical execution of 
the volume worthy in every respect of the character and value of the teachings it contains. 



HABERSHON (S. O.), M. D., 
Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. 

PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES 

OF THE ALIMENTARY CANAL, OESOPHAGUS, STOMACH, OJECUM, AND INTES- 
TINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra 
cloth. $2 50. 



HOBLYN (RICHARD D.), M. D. 
A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE 

COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, 
by Isaac Hays, M. D., editor of the " American Journal of the Medical Sciences." In one large 
royal 12mo. volume, cloth, of over 500 double columned pages. $1 50 



To both practitioner and student, we recommend 
this dictionary as being convenient in size, accurate 
in definition, and sufficiently full and complete for 
ordinary consultation —Charleston Med. Journ. 

We know of no dictionary better arranged and 
adapted. It is not encumbered with the obsolete terms 
of a bygone age, but it contains all that are now in 



use ; embracing every department of medical science 
down to the very latest date. — Western Lancet. 

Hoblyn's Dictionary lias long been a favorite with 
us. It is the best book of definitions we have, and 
ought always to be upon the student's table. — 
Southern Med. and Surg. Journal. 



JONES (T. WHARTON), F. R. S., 

Professor of Ophthalmic Medicine and Surgery in University College, London, <fcc. 

THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE 

AND SURGERY. With one hundred and seventeen illustrations. Third and revised Ameri- 
can, with additions from the secono London edition. In one handsome octavo volume, extra 
cloth, of 455 pages. $3 25. 

Seven years having elapsed since the appearance of the last edition of this standard work, very 
considerable additions have been found necessary to adapt it thoroughly to the advance of ophthal- 
mic science. The introduction of the ophthalmoscope has resulted in adding greatly to our know- 
ledge of the pathology of the diseases of the eye, particularly of its more deeply seated tissues, and 
Corresponding improvements in medical treatment and operative procedures have been introduced. 
All these matters the editor has endeavoured to add, bearing it) mind the character of the volume as a 
Condensed and practieul manual To accommodate this unavoidable increase in the size of the work, 
its form has been changed from a duodecimo to an octavo, and it is presented as worthy a continu- 
ance ol the favour which has been bestowed on former editions. 

A complete Beries of "test-types" for examining the accommodating power of the eye, will be 
found an important und useful addition. 



JONES (C. HANDFIELD), F.R.S., & EDWARD H. SIEVEKING, M.D., 

Assistant Pliysieiansund Lecturers in St. Mary's Hospital, London. 

A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, 

Revised. With three hundred und ninety-seven handsome wood engravings. In one large and 

beautiful octavo volume of nearly 750 pages, extra cloth. $3 . r iO. 

As u concise text-book, containing, in a condensed i obliged to glean from a great number of monographs, 
form, a complete outline of what is known in the and the field was bo extensive that .but fewcultivatea 
domain of Pathological Anatomy, it in perhaps the j it with any degree of success. Asa simple work 
best work in the English language. Its great merit of reference, therefore, it is of great value to the 
consists in its completeness and brevity, and in this student of pathological anatomy, and should be in 
respect it supplies a great desideratum in our lite- overy physician's library.— Western Lane* t. 
rature. Heretofore the student of pathology wus I 



HENRY C. LEA'S MEDICAL 



KIRKES (WILLIAM 

Demonstrator of Morbid Anatomy a 

A MANUAL OF PHYSIOLOGY. 

improved London edition. With two hundred 

12mo. volume, extra cloth, pp. 5S6. $2 25. 

This is a new and very much improved edition of 
Dr. Kirkes' well-known Handbook of Physiology. 
It combines conciseness with completeness, and is, 
therefore, admirably adapted for consultation by the 
busy practitioner. — Dublin Quarterly Journal. 

One of the very best handbooks of Physiology we 
possess — presenting just sucii an outline of the sci- 
ence as the student requires during his attendance 
upon a course of lectures, or for reference whilst 
preparing for examination.— Am. Medical Journal 

Its excellence is in its compactness, its clearness, 



SENHOUSE), M. D., 

tSt. Bartholomew's Hospital, &c. 

A new American, from the third and 
illustrations. la one large and handsome royal 



and its carefully cited authorities. It is the most 
convenientoftext-books. These gentlemen, Messrs. 
Kirkes and Paget, have the gift of telling us what 
we want to know, without thinking it necessary 
to tell us all they know. — Boston Med. and Surg. 
Journal. 

For the student beginning this study, and the 
practitioner who has but leisure to refresh his 
memory, this book is invaluable, as it contains all 
that it is important to know.— Charleston Mtd. 
Journal 



KNAPP'S TECHNOLOGY; or, Chemistry applied I LAYCOOK'S LECTURES ON THE PRINCf.- 
to the Arts and to Manufactures. Edited by Dr. PLES AND METHODS OF MEDICAL OB- 
Ronalds, Dr. Richardson, and Prof. W. R. | SERVATION AND RESEARCH. For the Use 
Johnson. In two handsome 8vo. vols., extra cloth, I of Advanced Students and Junior Practitioners. 
With about 500 wood engravings. $6 00. | In one royal 12mo. volume, extra cloth. Price $1. 



LALLEMAND AND WILSON. 
A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND 

TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by 

Henry J McDougall. Third American edition. To which is added ON DISEASES 

OF THE VESICUL^ SEMINALES; and their associated organs. With special refer- 
ence to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris 
Wilson, M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 75. 



LA ROCHE (Ft.), M . D., &c. 
YELLOW FEVER, considered in its Historical, Pathological, Etiological, and 

Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia 
from 1699 to 1854, with an examination of the connections between it and the fevers known under 
the same name in other parts of temperate as well as in tropical regions. In two large and 
handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. 
We have not time at present, engaged as we are, 

by day and by night, in the work of combating this 

very disease, now prevailing in our city, to do more 

than give this cursory notice of what we consider 

as undoubtedly the most able and erudite medical 

publication our country has yet produced. But in 

view of the startling fact, that this, the most malig- 
nant and unmanageable disease of modern times, 

has for several years been prevailing in our country 

to a greater extent than ever before; that it is no 



longer confined to either large or small cities, but 
penetrates country villages, plantations, and farm- 
houses; that it is treated with scarcely better suc- 
cess now than thirty or forty years ago; that there 
is vast mischief done by ignorant pretenders to know- 
ledge in regard to the disease, and in view of the pro- 
bability that a majority of southern physicians will 
be called upon to treat the disease, we trust that this 
able and comprehensive treatise will be very gene- 
rally read in the south.— Memphis Med. Recorder. 

BY THE SAME AUTHOR. 

PNEUMONIA ; its Supposed Connection, Pathological and Etiological, with Au- 
tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one 
handsome octavo volume, extra cloth, of 500 pages. $3 00. 



LEHMANN (C. G.) 

PHYSIOLOGICAL CHEMISTRY. Translated from the second edition hy 
George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry 
in the Medical Department of the University of Pennsylvania, with illustrations selected from 
Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large 
and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- 
trations. $6 00. 
The work of Lehmann stands unrivalled as the I The most important contribution as yet made to 

most comprehensive book of reference and informa- 1 Physiological Chemistry. — Am. Journal Med. Sci- 

tion extant on every branch of the subject on which I tnces, Jan. 1856. 

it treats. — Edinburgh Journal of Medical Science. \ 

BY THE SAME AUTHOR. 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, 

with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital 
Force, by Professor Samuel Jackson, M. D., of the University of Pennsylvania. With illus- 
trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. 



LUDLOW (J. L.), M. D. 
A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, 

Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To 
which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended 
and enlarged. With 370 illustrations. In one handsome royal 12mo. volume, ol 816 large 
pages, extra cloth, $3 25. 
We know of no better companion for the student | crammed into his head by the various professors to 

during the hours spent in the lecture room, or to re- whom he is compelled to listen. — Western Lanctt, 

fresh, at a glance, his memory of the various topics [ May, 1857. 



AND SCIENTIFIC PUBLICATIONS. 



21 



LYONS (ROBERT D.), K. C. C, 

Late Pathologist in-ehief to the British Army in the Crimea, &c. 

A TREATISE ON FEVER; or, selections from a course of Lectures on Fever. 

Being part of a course of Theory and Practice of Medicine. In one neat octavo volume, of 362 
pages, extra cloth; 



$2 25, 

This is an admirable work upon the most remark- 
able and most important class of diseases to which 
mankind are liable. — Med. Journ. of N. Carolina 
May, 1861. 

We have great pleasure in recommending Dr. 



Lyons' work on Fever to the attention of the pro- 
fession. It is a work which cannot fail to enhance 
the author's previous well-earned reputation, as a 
diligent, careful, and accurate observer. — British. 
Med. Journal, March 2, 1861. 



MONTGOMERY (W. F.), M. D., M. R. I. A., &c, 

Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. 

AN. EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. 

With some other Papers on Subjects connected with Midwifery. From the second and enlarged 
English edition. With two exquisite colored plates, and numerous wood-cuts. In one very 
handsome octavo volume, extra cloth, of nearly 600 pages. $3 75. 

A book unusually rich in practical suggestions. — 
Am Journal Med. Sciences, Jan. 1857. 

These several subjects so interesting in them- 
selves, and so important, every one of them, to the 
most delicate and precious of social relations, con- 
trolling often the honor and domestic peace of a 
family, the legitimacy of offspring, or the life of its 
parent, are all treated with an elegance of diction, 
fulness of illustrations, acuteness and justice of rea- 
soning, unparalleled in obstetrics, and unsurpassed in 
medicine. The reader's interest can never flag, so 



| fresh, and vigorous, and classical is our author's 
I style; and one forgets, in the renewed charm of 
I "ivery page, that it, and every line, and every word 
! has been weighed and reweighed through years of 
preparation ; that this is of all others the book of 
Obstetric Law, on each of its several topics; on all 
points connected with pregnancy, to be everywhere 
received as a manual of special jurisprudence, at 
j once announcing fact, affbrdingargument, establish- 
I ing precedent, and governing alike the juryman, ad- 
[ vocate,and judge. — N. A. Med.-Chir. Review. 



MEIGS (CHARLES D.), M. D., 

Lately Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. 

OBSTETRICS : THE SCIENCE AND THE ART. Fourth edition, revised 

and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octave 
volume, of seven hundred and thirty large pages, extra cloth, §5 00. 

From the Author's Preface. 

" [n this edition I have endeavored to amend the work by changes in its form ; by careful cor- 
rections of many expressions, and by a few omissions and some additions as to the text. 

"The Student will find that I have recast the article on Placenta Prsevia, which I was led to do 
out of my desire to notice certain new modes of treatment which I regarded as not only ill founded 
as to the philosophy of our department, but dangerous to the people. 

" In changing the form of my work by dividing it into paragraphs or sections, numbered from 1 
to 959, 1 thought to present to the reader a common-place book of the whole volume Such a table 
of contents ought to prove both convenient and useful to a Student while attending public lectures." 

A work which has enjoyed so extensive a reputation and has been received with such general 
favor, requires only the assurance that the author has labored assiduously to embody in his new 
edition whatever has been found necessary to render it fully on a level with the most advanced 
stale of the subject. Both as a text-book tor the student and as a reliable work of reference for 
the practitioner, it is therefore to be hoped that the volume will be found worthy a continuance of 
the confidence reposed in previous editions. 

BY THE SAME AUTHOR. 

WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Leo- 

tures to his Class Fourth and Improved edition. In one large and beautifully printed octave 

volume, extra cloth, of over 700 pages. $5 00. 

which cannot fail to recommend the volume to tha 
ittention of the reader. — Ranking's Abstract. 



I n Other respects, in our estimation, too much can- 
not be laid in praise of this work. It abounds with 
beautiful passages, and for conciseness, for origin- 
ality, and for all that is commendable in a work on 
the diseases of females, it is not excelled, and pro- 
bably not, eaualled in the F.nglish language. On the 
whole, we know of no work on the diseases of wo- 
rni'n which we can so cordially commend to the 
Student and practitioner aa the one before us. — Ohio 
Med. and Surg. Journal. 

The body of the bonk Is worthy of attentive con- 
sideration, and is evidently the production "I B 
clever, thoughtful, and sagacious physician. Dr. 
Meigs's letters on the diseases of the external or- 
gans, contain many interesting and rare eases, and 
many instructive observations. We take out leave 
Of Dr Meigs, with a high opinion of his talents and 
originality.— The British and Foreign Medico-Vhi- 
rurgical Review. 

Every chapter is replete with practical instruc- 
tion, and bears the impress of being the Composition 

of an acute and experienced mind. There isatei Be- 
lies*, and at the same tune an accuracy in Iiih de- 
scription of symptoms, and in the rulesfor diaguoais, 



It contains a vast amount of practical knowledge, 
:>y one who has accurately observed and retained 
the experience of many years. — Dublin Quarterly 
Journal. 

Full of important matter, conveyed in a ready and 
agreeaole manner.— St. Low's Med. and Surg. Jour . 

There is nn olf-hand fervor, aglow, and a warm- 
neartedness infecting the erf irt of Dr. Meigs, which 
is entirely captivating., and which absolutely hur- 
ries the reader through from beginning to end. Be- 
sides, the book teems with solid instruction, and 
it shows the very highest evidence of ability, viz., 
the clearness with which the information is pre- 
sented. We know of no better test of one's under- 
Jtanding a subject than the evidence of the power 
)f lucidly explaining it. The most elementary, as 
well as the obscurest subjects, under the pencil of 
Prof. Meigs, are isolated and made to stand out in 
such IjoiU relief, as CO produce distinct impressions 
apon the mind and memory of the reader.— - Tk* 
Charleston Med. Journal. 



£2 



HENRY C. LEA'S MEDICAL 



MEIGS (CHARLES D.) M. D., 
Lately Professor of ObBtetrics, &c, in Jefferson Medical College, Philadelphia. 

ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED 

FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome 

octavo volume, extra cloth, of 365 pages. $2 0<>. 

The instructive and interesting author of this j leetable book. * * * This treatise upon child- 
work, whose previous labors have placed his coun- bed fevers will have an extensive sale, being des- 
trymen under deep and abiding obligations, again | tined, as it deserves, to find a place in the library 
challenges their admiration in the fresh and vigor of every practitioner who scorns tolag in thereab- 
out, attractive and racy pages before us. It is a de- ' Nashville Journal of Medicine and Surgery. 



MACLISE (JOSEPH), SURGEON. 
SURGICAL ANATOMY. Forming one volume, very large imperial quarto, 

With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- 
taining- one hundred and ninety Figures, many of them the size of life. Together with copious 
and explanatory letter-press. Stroiigiy and handsomely bound in extra doth, being one of the 
cheapest and best executed Surgical works as yet issued in this country. SI 4 00 

These plates will be found of the highest practical value, either for consulta- 
tion in emergencies or to refresh the recollections of the dissecting room. 

%* The size of this work prevents its transmission through the post-office as a whole, but those 
who desire to have copies forwarded by mail, can receive them in five parts, done up in stout 
wrappers. Price $12 00. 

One of the greatest artistic triumphs of the age I A work which has no parallel in point of accu- 
in Surgical Anatomy. — British American Medical racy and cheapness in the English language. — N. Y 



Journal. 

No practitioner whose means will admit should 
fail to possess it. — Banking's Abstract. 

Too much cannot be said in its praise; indeed, 
we have not language to do it justice.— Ohio Medi- 
tal and Surgical Journal. 

The most accurately engraved and beautifully 
colored plates we have ever seen in an American 
bock — one of the best and cheapest surgical works 
«ver published.— Buffalo Medical Journal. 

It is very rare that so elegantly printed, so well 
illustrated, and so useful a work, is offered at so 
moderate a price.— Charleston Medical Journal. 

Its plates can boast a superiority which places 
them almost beyond thereach of competition.— Medi- 
cal Examiner. 

Country practitioners will find these plates of im- 
mense value — N. Y. Medical Gazette. 



Journal of Medicine. 

We are extremely gratified to announce to ths 
profession the completion of this truly magnificent 
work, which, as a whole, certainly stands unri- 
valled, both for accur-acy of drawing, beauty of 
coloring, and all the requisite explanations of tha 
subject in hand.— Th* Nti* Orleans Medical and 
Surgical Journal. 

This is by far the ablest work on Surgical Ana- 
tomy that has come under our observation. W» 
know of no other work that would justify a stu- 
dent, in any degree, for neglect of actual dissec- 
tion. In those sudden emergencies that so often 
arise, and which require the instantaneous command 
of minute anatomical knowledge, a work of this kind 
keeps the details of the dissecting-room perpetually 
fresh in the memory. — Th* Western Journal of Mtdi- 
cins and Surgery. 



MILLER (HENRY), M. D., 

Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. 

PRINCIPLES AND PRACTICE OF OBSTETRICS, &C. ; including the Treat- 
ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent 
cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- 
tavo volume, of over 600 pages, extra cloth. $3 75. 



We congratulate the author that the task is done. 
We congratulate him that he has given to the medi- 
cal public a work which will secure for him a high 
and permanent position among the standard autho- 
rities on the principles and practice of obstetrics. 
Congratulations are not less due to the medical pro- 
fession of this country, on the acquisition of a trea- 
tise embodying the results of the studies, reflections, 
and experience of Prof. Miller.— Buffalo Medical 
Journal. 

In fact, this volume must take its place among the 
Standard systematic treatises on obstetrics; a posi- 



tion to which its merits justly entitle it— The Cin- 
cinnati Lancet and Observer. 

A most respectable and valuable addition to our 
home medical literature, and one reflecting credit 
alike on the author and the institution to which he 
is attached. The studenfwill find in this work a 
most useful guide to his studies; the country prac- 
titioner, rusty in his reading, can obtain from its 
pages a fair resume of the modern literature of the 
science; and we hope to see this American produc- 
tion generally consulted by the profession — Vm. 
Med. Journal. 



MACKENZIE (W.), M. D., 

Surgeon Oculist in Scotland in ordinary to Her Majesty, 4.C&C. 

A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE 

EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of 
the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- 
larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to 
Wills Ho*pital,&c. &c. In one very large and handsome octavo volume, extra cloth, with plales 
and numerous wood-cuts $b 50. 



The treatise of Dr. Mackenzie indisputably holds 
the firstplace, and forms, in respect of learning and 
research, an Encyclopaedia unequalled in extent by 
any other work of the kind, either English or foreign 
— Dixon on Diseases of th* Ey*. 



We consider it the duty of every one who has the 
love of his profession and the welfare of his patient 
at heart, to make himself familiar with this the mc.st 
complete work in the English language upon the dis- 
eases of the eye.— Med. Timtsand Gazett*. 



AND SCIENTIFIC PUBLICATIONS. 



23 



MILLER (JAMES), F. R. S. E., 
Professor of Surgery in the University of Edinburgh, &c. 

PRINCIPLES OF SURGERY. Fourth American, from the third and revised 

Edinburgh edition. In one large and very beautiful volume, extra cloth, of 700 pages, with 
twt hundred and forty illustrations on wood. $3 75. 

BY THE SAME AUTHOR. 

THE PRACTICE OF SURGERY. Fourth American from the last Edin- 
burgh edition. Revised by the American editor. Illustrated by three hundred and sixty- four 
engravings on wood. In one large octavo volume, extra cloth, of nearly 700 pages. $3 75. 



No encomium of ours could add to the popularity 
of Miller's Surgery. Its reputation in this country 
is unsurpassed by that of any other work, and, when 
taken in connection with the author's Principles of 
Surgery, constitutes a whole, without reference to 
whicb unconscientious surgeon would be willing to 
prueticehisart. — Southern Med . and Surg . Journal. 

iris seldom that two volumes have ever made so 
pmfound an impression in so short a time as the 
" Principles" and the "Practice" of Surgery by- 
Mr. Miller — or so richly merited the reputation they 
have acquired. The author is an eminently sensi- 
ble, practical, and well-informed man, who knows 
exactly what he is talking about and exactly how to 
talk it.— Kentucky Medical Recorder. 

By the almost unanimous voice of the profession, 



his works, both on the principles and practice of 
surgery have been assigned the highest rank. If we 
were limited to but one work on surgery, that one 
should be Miller's, as we regard it as superior to all 
others. — St. Louis Med. and Surg. Journal. 

The author has in this and his " Principles," pre- 
sented to the profession one of the most complete and 
reliable systems of Surgery extant. His style of 
writing is original, impressive, and engaging, ener- 
getic, concise, and lucid. Few have the faculty of 
condensing so much in small space, and at the same 
time so persistently holding theattention. Whether 
as a text-book for students or a book of reference 
for practitioners, it cannot be too strongly recom- 
mended. — Southern Journal of Med. and Physical 
Sciences. 



MORLAND (W. W.), M. D., 
Fellow of the Massachusetts Medical Society, &c. 

DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, 

Pathology, and Trealment. With illustrations. In one large and handsome octavo volume, of 
about 600 pages, extra clolh. $3 50. 



Taken as a whole, we can recommend Dr. Nor- 
land's compendium as a very desirable addition to 
the library of every medical or surgical practi- 
tioner.— Br it. and For. Med.-Ch ir. Rev., A pril, 1S59. 

Every medical practitioner whose attention has 
been to any extent attracted towards the class of 
diseases to which this treatise relates, must have 
often and sorely experienced the want of some full, 
yet concise recent compendium to which he could 

BY THE SAME AUTHOR. 

THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF 

THE ELEMENTS OF THE URINARY SECRETION. Being the Dissertation to which the 
Fiske Fund Prize was awarded, July 11, 1801. In one small octavo volume, S3 pages, extra 
cloth. 75 cents. 



refer. This desideratum has been supplied by Dr. 
Morland, and it has been ably done. He has placed 
before us a full, judicious, and reliable digest. 
Each subject is treated with sufficient minuteness, 
yet in a succinct, narrational style, such as to reider 
the wori one of great interest, and one which will 
prove in the highest degree useful to the general 
practitioner. — N. Y. Joufn. of Medicine, 



MAVNR'S DISPKNSATORY AND THERA- 
PEUTICAL REMEMBRANCER. With every 
Practical Formula contained in the three British 

| Pharmacopoeias Edited, with the addition of the 
Formulae of the U. S. Pharmacopoeia, by R. E. 
"Griffith, M. D 1 12mo. vol. ex.cl.,300 Dp. 75c. 



MALGAIGNE'S OPERATIVE SURGERY, based 
on Normal and Pathological Anatomy. Trans- 
lated from the French by Frederick Brittan, 
A. B.,M.D. Withnumerousillustrationsonwood. 
In one handsome octavo volume, extra cloth, of 
nearlv six hundred pages. 5?2 50. 



NELIGAN (J. MOORE), M. D., M. R. I. A., &c. 
ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra 

cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of 

disease. $5 50. 

This beautiful volume is intended as a complete and accurate representation of all the varieties 
of Diseases oi the Skin. While it can be consulted in conjunction with any work on Practice, it has 
especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the 
profession s e years since. The publishers feel justified in saying that few more beautifully exe- 
cuted plutes have ever been presented to the profession of this country. 



Ndigan'B Atlas of Cutaneous Diseases supplies a 
long existent desideratum much felt by the largest 
elan rrf mir profession. It presents, in quarto size, 
lfi plates, e»cli containing from 3 to fl figures, anu 
forming in all a total of !MI distinct representations 
Of the different Bpecies of skin affections, grouped 
together in genera or families. The illustrations 
have t"cn taken from nature, and have been copied 
with such fidelity that they present B Striking picture 
Of life; in which the reduced scale aptly serves to 



give, at a coup d'ozil, the remarkable peculiarities 
of each individual variety. And while thus the dis- 
ease is rendered more definable, there is yet no loss 
of proportion incurred by the necessary concentra- 
tion. Bach figure is highly colored, and so truthful 
hai the artist Been that the most fustid'ous observer 
could not justly take exception to the correctness of 
the execution of the pictures under his scrutiny. — 
Montreal Med. Chroniclt. 



BY THE SAME AUTHOR. 



A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fourth 
American edition, in one neut royal 12mo. volume, extra cloth, of 334 pages. $1 50. 



24 



HENRY C. LEA : S MEDICAL 



NEILL (JOHN), M. D., 

Surgeon to the Pennsylvania Hospital, &c; and 
FRANCIS GURNEY SMITH, M.D., 

Professor of Institutes of Medicine in the Pennsylvania Medical College. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES 

OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised 
and improved. In one very large and handsomely printed royal 12mo. volume, of about one 
thousand pasres, with 374 wood-cuts, extra cloth, 84 00. Strongly bound in leather, with raised 
bands. $4 75. 

This work is again presented as eminently worthy of the favor with which it has hitherto 
been received. As a book for daily reference by the student requiring a guide to his more elaborate 
text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate 
examination, or as a source from which the practitioners of older date may easily and cheaply acquire 
a knowledge of the changes and improvement in professional science, its reputation is permanently 
established. 



The best work of the kind with which we are 
acquainted. — Med. Examiner. 

Having: made free use of this volume in our ex- 
aminations of pupils, we can speak from experi- 
ence in recommending it as an admirable compend 
for students, and as especially useful to preceptors 
who examine their pupils. It will save the teacher 
much labor by enabling him readily to recall all of 
the points upon which his pupils should be ex- 
amined. A work of this sort should be in the nands 
of every one who takes pupils into his office with a 
view of examining them ; and this is unquestionably 
thebestof its class. — Transylvania Med. Journal. 



In the rapid course of lectures, wheTe work for 
the students is heavy, and review necessary for an 
examination, a compend is not only valuable, but 
it is almost a sine qua non. The one before us is, 
in most of the divisions, the most unexceptionable 
of all books of the kind that we know of. Tho 
newest and soundest doctrines and the latest im- 
provements and discoveries are explicitly, though 
concisely, laid before the student. There is a class 
to whom we very sincerely commend this cheap book 
as worth its weight in silver— that class is the gradu- 
ates in medicine of more than ten years' standing, 
who have not studied medicine since. — The Stetho- 
scope. 



PIRRIE (WILLIAM), F. R. S. E., 

Professor of Surgery in the University of Aberdeen . 

THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John 

Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon tothe Pennsylvania 

Hospital, &c. In one very handsome 8vo. volume, extra cloth, of 780 pages, with 316 illustrations. 

£3 75. 

We know of no other surgical work of a reason- rately discussed the principles of surgery, and a 
able size, wherein there is so much theory and prac- safe and effectual practice predicated upon them, 
tice, or where subjects are more soundly or clearly Perhaps no work upon this subject heretofore issued 
taught. — The Stethoscope . I is so full upon the science of the art of surgery. — 

Prof. Pirrie, in the work before us, has elabo- I Nashville Journal of Medicine and Surgery . 



PEREIRA (JONATHAN), M.D. 

EDITED BY PROF. H. C. WOOD. 

MATERIA MEDICA AND THERAPEUTICS; being an Abridgment of tbe 

late Dr. Pereira's Elements of Materia Medica, arranged in conformity with the British Pharma- 
copoeia, and adapted to the use of Medical Practitioners, Chemists, and Druggists, Medical and 
Pharmaceutical Students, &c. By F. J. Farre, M. D., Senior Physician to St. Bartholomew's 
Hospital, and London Editor of the British Pharmacopoeia; assisted by Robert Bentley, 
M.R. C.S., Professor of Materia Medica and Botany to the Pnarmaceutical Society of Great 
Britain; and by Robert Warington, F. R. S., Chemical Operator to the Society of Apothecaries. 
With numerous additions and references to the United States Pharmacopoeia, by Horatio C. 
Wood, M. D., Professor of Botany in the University of Pennsylvania. In one large and hand- 
some octavo volume of about y00 pages, with numerous illustrations. (Preparing.) 



ROBERTS (WILLIAM) M. D., 

Physician to the Manchester Ruyal Infirmary, Lecturer on Medicine in the Manchester School of 
Medicine, &c. 

A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, 

including Urinary Deposits. Illustrated by numerous cases and engravings. In one handsome 
octavo volume of over 500 pages, extra cloth. Price $4 50. (Now Ready.) 
The want has for some time been felt of a work which should render accessible to the American 
profession in a compendious and convenient form, the results of the numerous and important re- 
searches which have of late years elucidated the pathology of Urinary and Renal Diseases. It has 
been the aim of the author in the present volume to set forth in a form divested of undue techni- 
cality, Ihe practical condition of the subject in its most advanced stage of progress. In endeavor- 
ing to accomplish this, he has retrained from crowding the volume with minute chemical and phy- 
siological details, which would unfit it for its object of affording to the physician a guide in his daily- 
practice, and to the student a condensed and intelligible compendium of all that is practically im- 
portant on the subject. To aid in this, numerous cases and illustrations have been introduced 
throughout the work. 

Tbe book is beyond question the mnst comprehen- I possess in the English language. — British Medical 
Bive work on Urinary and Renal Diseases, con- Journal. 
sidered in their strictly practical aspect, that we | 



AND SCIENTIFIC PUBLICATIONS 



25 



PARRISH (EDWARD), 

Professor of Materia Medica in the Philadelphia College of Pharmacy. 

A TREATISE ON PHARMACY. Designed as a, Text- book for the Student, 

and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 

Third edition, greatly improved. In one handsome octavo volume, of 850 pages, with several 

hundred Illustrations," extra cloth. $5 00. (Just Issued.) 

Though for some time out of print, the appearance of a new edition of this work has been de- 
layed for the purpose of embodying in it the results of the new U. S. Pharmacopoeia. The pub- 
lication of this latter has enabled the author to complete his revision in the most thorough manner. 
Those who have been waiting for the work may therefore rely on obtaining a volume completely 
on a level with the most advanced condition of pharmaceutical science. 

The favor with which the work has thus far been received shows that the author was not mis- 
taken in his estimate of the want of a treatise which should serve as a practical text-book for all 
engaged in preparing and dispensing medicines. Such a guide was indispensable not only to the 
educated pharmaceutist, but also to that large class of practitioners throughout the country who 
are obliged to compound their own prescriptions, and who during their collegiate course have no 
opportunity of obtaining a practical familiarity with the necessary processes and manipulations. 
The rapid exhaustion of two large editions is evidence that the author has succeeded in thoroughly 
carrying out his object. Since the appearance of the last edition, much has been done to perfect 
the science ; the new Pharmacopoeia has introduced many changes to which the profession must 
conform ; and the author has labored assiduously to embody in his work all that physicians and 
pharmaceutists can ask for in such a volume. The new matter alone will thus be found worth 
more than the very moderate cost of the work to those who have been using the previous editions. 



All that we can say of it is that to the practising 
physician, and especially the country physician, 
Who is generally his own apothecary, there is hard- 
ly any book that might not better be dispensed with. 
It is at the same time a dispensatory and a pharma- 
cy.— Louisville Review. 

A careful examination of this work enables us to 
speak of it in the highest terms, as being the best 
treatise on practical pharmacy with which we are 
acquainted, and an invaluable vide-mecum, not only 
to the apothecary and to those practitioners who 
are accustomed to prepare tt eir own medicines, but 
to every medical man and medical student. — Boston 
Med. and Surg. Journal. 

This is altogether one of the most useful books 
we have seen. It is just what we have long felt to 
be needed by apothecaries, students, and practition- 
ers of medicine, most of whom in this country have 
to put up their own prescriptions. It bears, upon 
every page, the impress of practical knowledge, 
conveyed in a plain common sense manner, and 
adapted to the comprehension of all who may read 
it. — Southern Med. and Surg. Journal. 

That Edward Parrish, in writing a book upon 
practical Pharmacy some few years ago — one emi- 
nently original and unique — did the medical and 
pharmaceutical professions a great: and valuable ser- 
vice, no one, we think, who has had access to its 
pages will deny; doubly welcome, then, is this new 



edition, containing the added results of his recent 
and rich experience as an observer, teacher, and 
practical operator in the pharmaceutical laboratory. 
The excellent plan of the first is more thoroughly, 
— Peninsular Med. Journal, Jan. 1860. 

Of course, all apothecaries who have not already 
a copy of the first edition will procure one of this; 
it is, therefore, to physicians residing in the country 
and in small towns, who cannot avail themselves of 
the skill of an educated pharmaceutist, that we 
would especially commend this work. In it they 
will find all that they desire to know, and should 
know, but very little of which they do really icnow 
in reference to this important collateral branch of 
their profession; for it is a well established fact, 
that, in the education of physicians, while the sci- 
ence of medicine is generally well taught, very 
little attention is paid to the art of preparing them 
for use, and we know not how this defect can be so 
well remedied as by procuring and consulting Dr. 
Parrish's excellent work. — St. Louis Med. Journal 
Jan. 1860. 

We know of no work on the subject which would 
be more indispensable to the physician or student 
desiring information on the subject of which it treats. 
With Griffith's " Medical Formulary" and this, the 
practising physician would be supplied with nearly 
or quite alt the most useful infornation on the sub- 
ject.— Charleston Med. Jour. and Review, Jan. 1860. 



PEASLEE (E. R.), M . D., 
Professor of Physiology and General Pathology in the New York Medical College. 

HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; 
for the use of Medical Students. With four hundred and thirty-four illustrations. In one hand- 
some octavo volume, extra cloth, of over 600 pages. $3 75. 
It embraces a library upon the topics discussed 

within itself, and is just what the teacher and learner 

need. We have not only the whole subject of His- 



tology, interesting in itself, ably and fully discussed, 
but what is of infinitely greater interest to the stu- 
iifni , because of greater practical value, are its re- 
lations to Anatomy, Physiology, and Pathology, 
which are here fully and satisfactorily set forth. — 
Nashville Journ. of Med. andSurgery. 



We would recommend it as containing a summary 
of all that is known of the importantsubjeets which 
it treats ; of all that is in the great works of Simon 
and Lehinann,und the organic chemists in general. 
Master this one volume, and you know all that is 
known of the great fundamental principles of medi- 
cine, and we have no hesitation in saying that it 
is an honor to the American medical profession— 
St. Louis Med. and Surg. Journal. 



ROKITANSKY 

Curator of the Imperial Pathological Museum 

A MANUAL OP PATHOLOGICAL 

bound in two, extra cloth, of about 1200 pages, 
king, C. H. Moore, and G. E. Day. $7 50. 
The profession is too well acquainted with the re- 
putation of Rokitansky'a work to need our assur- 
ance that tins is one of the most profound, thorough, 
and valuable books ever issued from the medical 
press. It is sui generis, and has no standard of com- 
parison. His only necessary to announce that il in 
issued in a form as cheap as is compatible with its 



(CARL), M.D., 

and Professor at the University of Vienna, &c 

ANATOMY. Four volumes, octavo. 
Translated by W. E. Swaine, Edward Sievb- 

size and preservation, and its sale follows as a 
matter ol course. No library can be called com 
plete without it. —Buffalo Med. Journal. 

An attempt to give our readers any adequate idea 
of the vast amount of instruction accumulated in 
these volumes, would be feeble and hopeless — 
Western Lancet. 



EOYLE'S MATERIA MEDICA AND THERAPEUTICS; including the 

Preparations of the Pharmacopueias of London, Edinburgh, Lublin, and of the United States. 
With many new medicines. Edited by Joskph Carson, M. D. With ninety-eight illustration*' 
In one large octavo volume, extra cloth, of about 700 pages. $3 00. 



26 



HENRY C. LEA'S MEDICAL 



RlGBY (EDWARD), M.D., 

Senior Physician to the General Lying-in Hospital, &e. 

A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. 
Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. 

BY THE SAME AUTHOR. 

ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. 

In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. 



RAMS BOTH AM (FRANCIS H.), M.D. 
THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND 

SURGERY, in reference to the Process- of Parturition. A new and enlarged edition, thoroughly 
revised by the Author. With Addition s by W.V. Keating, M. D., Professor of Obstetrics, &c, in 
the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume, 
of 650 pages, strongly bound in leather, with raised bands; with sixty- four beautiful Plates, and 
numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $>7 00. 

From Prof. Hodge, of the University of Pa. 
To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being 
the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout 
our country. 



It is unnecessary to say anything in regard to the 
utility of this work. It is already appreciated in our 
country for the value of the matter, the clearness of 
its style, and the fulness of its illustrations. To the 
physician's library it is indispensable, while to the 
student as a text-book, from which to extract the 
material for laying the foundation of an education on 
obstetrical science, it has no superior. — Ohio Med 
and Surg. Journal. 

The publishers have secured its success by the 



truly elegant style in which they have brought it 
out, excelling themselves in its production, espe- 
cially in its plates. It is dedicated to Prof. Meigs, 
and has the emphatic endorsement of Prof. Hodge, 
as the best exponent of British Midwifery. We 
knt.w of no text-book which deserves in all respects 
to be more highly recommended to students, and we 
could wish tosee it in the hanusof every practitioner, 
for they will find it invaluable for reference. — Med. 
Gazette. 



RICORD (P.), M. D. 
LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M. D In one 

neat octavo volume, of 270 pages, extra cloth. $2 00. 



SMITH (HENRY H.), M. D., AND HO RN ER (W I L L I AM E.),M.D. 
AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. 

In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful 

figures. $4 50. 

The plan of this Atlas, which renders it so pe- 1 of thekind that hasyet appeared ; and we must add, 
culiurly convenient for the student, and its superb | the very beautiful manner in which it is "got up" 
artistical execution, have been already pointed out j is so creditable to the country as to be flattering 
We must congratulate the student upon the comple- to our national pride. — American Medical Journal. 
tion of this Atlas, as it is the most convenient work | 



SMITH (EDWARD), M.D., LL.D., F.R.S. 

Assistant Physician to the Hospital for Consumption and Diseases of the Chest, Brcmpton, &c. 

CONSUMPTION; ITS EARLY AND REMEDIABLE STAGES. In one 

neat octavo volume of 254 pages, extra cloth. $2 25. 



One-half of Dr. Smith's work is devoted to the 
treatment of Tuberculosis. We find in this portion 
of the work no occasion to join issue with the au- 
thor ; but, on the contrary, much which we would 
commend to the reader's attention. Dr. Smith at- 
taches far greater importance to hygienic measures 



than to drugs in the treatment of the disease. In 
taking leave of the work, we would express the 
hope that the author will furnish occasions for the 
renewal of our intercourse as a reader, if not asa 
I ieviewer. — Am. Med. Journal, Jan. 1863. 



SHARPEY (WILLIAM), M.D., JONES QUAIN, M.D., AND 

RICHARD QUAIN, F. R. S., &c. 

HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, 

M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octave 
volumes, extra cloth, of about thirteen hundred pages. With over 500 illustrations $6 00. 



80LLYON THE HUMAN BRAIN; itsStructure, 
Physiology, and Diseases. From the Second and 
much enlargeu London edition, lii one octavi 
volume, extra cloth, of 50(1 pages, with 12(1 wood 
cuts. 82 50. 

SKEY'S OPERATIVE SURGERY. In one verj 



handsome octavo volume, extra cloth, of over 650 
pages, with about one hundred wood-cuts. 83 25. 
SIMON > GENERAL PATHOLOGY, as conduc- 
ive to the Establishment of Rational Principles 
for the prevention anc Cure of Disease In one 
octavo volume, extra cloth, of 212 pages. $1 25. 



AND SCIENTIFIC PUBLICATIONS 



•21 



STILLE (ALFRED), M.D., 

Professor of the Theory and Practice of Medicine in the University of Pennsylvania. 

THERAPEUTICS ASD MATERIA MEDICA; a Systematic Treatise on the 

Action and Uses of Medicinal Agents, including their Description and History. Second Edition, 

revised and enlarged. In two large and handsome octavo volumes, extra cloth. $10 00. 

This work is designed especially for the student and practitioner of medicine, and treats the various 
articles of the Materia Medica from the point of view of the bedside, and not of the shop or oi the 
lecture-room. While thus endeavoring to give all practical information likely to be useful with 
respect to the employment of special remedies in special affections, and the results to be anticipated 
from their administration, a copious Index of Diseases and their Remedies renders the work emi- 
nently fitted for reference by showing at a glance the different means which have been employed, 
and enabling the practitioner to extend his resources in difficult cases with all that the experience 
o/ the profession has suggested. 

The speedy demand for another edition of this work shows that it has acceptably filled an acknow- 
ledged want No exertion of the auihor has been wanting to render it worthy a continuance of the 
favor with which it has been received, while an alteration in the typographical arrangement has 
accommodated the additions without increasing unduly the size of the volumes. 

Rarely, indeed, have we had submitted to us a i tioned, Stille. His great work on " Materia Medi- 
k on medicine so ponderous in its dimensions ! ca and Therapeutics," published last year, in two 

of some sixteen hundred page3, 



as that now before us, and yet so fascinating 
contents. It is, therefore, with a peculiar gratifi- 
cation that we recognize in Dr. Stille the posses- 
sion of many of those more distinguished qualifica- 
tions which entitle him to approbation, and which 
justify him in coming before his medical brethren 
as an instructor. A comprehensive knowledge, 
tested by a sound and penetrating judgment, joined 
t<> a love of progress — which a discriminating spirit 
of inquiry has tempered so as to accept nothing new 
because it is new, and abandon nothing old because 
it is old. but which estimates either accorting to its 
relations to a just logic and experience — manifests 
itself everywhere, and gives to the guidance of the 
auihor all 'he assurance of safety which the diffi- 
culties of his subject can allow. In conclusion, we 
earnestly advise our readers to ascertain for them- 
selves, by a study of Dr. Stille's volumes, the great 
value and interest of the stores of knowledge they 
present. We have pleasure in referring rather to 
the ample treasury of undoubted truths, the real and 
assured conquest of medicine, accumulated by Dr. 
Stille in his pages ; and commend the sum of his la- 
bors to the attention of our readers, as alike honor- 
able to our science, and creditable to the zeal, the 
candor, and the judgment of him vvho has garnered 
the whole so carefully. — Edinburgh Med. Journal. 
The most recent authority is the one last men- 



octavo volumes, 

while it embodies the results of the labor of others 
up to the time of publication, is enriched with a 
great amount of original observation and research. 
We would draw attention, by the way, to the very 
convenient mode in which the Index is arranged in 
this work. There is first an 1( Index of Remedies ;' 
next an "Index of Diseases and their Remedies." 
Such an arrangement of the Indices, in our opinion, 
greatly enhances the practical value of books of this 
kind. In tedious, obslinate cases of disease, where 
we have to try one remedy after another until our 
stock is pretty nearly exhausted, and we are almost 
driven to our wit's end, such an index as the second 
of the two just mentioned, is precisely what we 
want. — London Med. Times and Gazette, April, 1861. 
We think this work will do much to obviate the 
reluctance to a thorough investigation of this branch 
of scientific study, for in the wide range of medical 
literature treasured in the English tongue, we shall 
hardly find a work written in a style more clear and 
simple, conveying forcibly the facts taught, and yet 
free from turgidity and redundancy. There is a fas- 
cination in its pages that will insure to it a wide 
popularity and attentive perusal, and a degree of 
usefulness not often attained through the influence 
of a single work. 



SIMPSON (J. Y.), M. D., 

Professor of Midwifery, &c, in the University of Edinburgh,&e. 

CLINICAL LECTURES ON THE DISEASES OP WOMEN. With nu- 

meious illustrations. In one handsome octavo volume, of over 500 pages, extra cloth, $4 00. 

The principal topics embraced in the Lectures are Vesico-Vaginal Fistula, Cancer of the Uterus, 
Treatment of Carc.noma by Caustics, Dysmenorrhea, Amenorrhoea, Closures, Contractions, &c, 
of the Vagina, Vulvitis, Causes of Death after Surgical Operations, Surgical Fever, Phlegmasia 
Dolens, Coccyodinia, Pelvic Cellulitis, Pelvic Hsematoma, Spurious Pregnancy, Ovarian Dropsy, 
Ovariotomy, Cranioclasm, Diseases of the Fallopian Tubes, Puerperal Mania, Sub-Involution and 
Super-Involution of the Uterus, tec. &c. 

As a series of monographs on these important topics— many of which receive little attention 
in the ordinary text-books — elucidated with the extensive experience and readiness of resource for 
which Proiessor Simpson is so distinguished, there are lew practitioners who will not find in its 
pages matter of the utmost importance in the treatment of obscure and difficult cases. 

SALTER (H. H.>, M. D. 
ASTHMA; its Pathology, Causes, Consequences, and Treatment. In one vol. 

8vo., extra cloth. $2 50. 



The portion of Dr. Salter's work which is devoted 
to treatment, is of greut practical interest and value. 
It would be necessary to loilow him step by step 
in his remarks, not only on tin- medicinal, but also 
on the dietetic and hygienic treatment of the disease, 
[n Order in convey a just not ion 01 tiie pructicul value 
of this part of his work. This our space forbius, 



and this we shall little regret, if, by our silence, 
we should induce Our readers to possess themselves 
of the book itself; a book which, w i thou t uoubt, de- 
serves to be ranked among the most valuable of re- 
cent contributions to the medical literature of this 
country.— Ranking' s Abstract, Jan., 19UI. 



SLADE iO. D.), M. D. 
DIPHTHERIA: its Nature and Treatment, with an account of the History of 

its Prevalence in various countries. Second and revised edition. In one neat royal 12tno. 

volume, extra cloth. $1 25. (Just Issued.) 

The original eBgay of Dr. Slade, to which the I observation. In its present form, the work furnishes 
Fibke Kund prize lor I860 was awarded, appeared to the Btudtnt and young practitioner a very faithful 
originally m this Journal. In the edition before u« | and usefnl exposition of thi principal facts that are 
the essay has been n vised with evicent care, wule I now known in respect to the nature of diphtheria, 
such additions have been male to it us were sug Its causes-and treatment, — Am.Joum Med. Sciences, 
gested by tne author's subsequent experience and | J.iu. lbt>5. 



2S 



HENRY C. LEA'S MEDICAL 



SARGENT (F. W.), M. D. 
ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. 

New edition, wiih an additional chapter on Military Surgery. One ifandsome royal 12mo. vol., 

of nearly 400 pages, with 184 wood cuts. Extra cloth, SI 75. 

The value of this work as a handy and convenient manual for surgeons engaged in active duty, has 
induced the publishers to render it more complete for those purposes by the^addition of a chapter 
on gun-shot wounds and other matters peculiar to military surgery. In its present form, there- 
tore, it will be found a very cheap and convenient vade-mecum for consultation and relerence in 
the daily exigencies of military as well as civil practice. 



We consider that no better book could be placed 
in the hands of an hospital dresser, or theyoung sur- 
geon, whose education in this respect has not been 
perfected. Wc most cordially commend this volume 
as one which the medical student should most close- 
ly study, to perfect himself in these minor surgical 
operations in which neatness and dexterity are so 
iiiuch required, and on which a great portion of his 
reputation as a future surgeon must evidently rest. 
And to the surgeon in practice it must prove itself 
a valuable volume, as instructive on many points 
which he may have forgotten. — British American 
Journal, May, 1862. 



The instruction given upon the subject of Ban- 
daging, is alone of great value, and while the author 
modestly proposes to instruct the students of medi- 
cine, and the younger physicians, we will say that 
experienced physicians will obtain many exceed- 
ingly valuable suggestions by its perusal. It will 
be found one of the most satisfactory manuals for re- 
ference in the field, or hospital yet published; thor- 
oughly adapted to the wants of Military surgeons, 
and at the same time equally useful for ready and 
convenient, reference by surgeons everywhere. — 
Buffalo Med. and Surg. Journal, June, 1862. 



SMITH (W. TYLER), M. D., 

Physician Accoucheur to St. Mary's Hospital, &c. 

ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OP 

OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $150. 

BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT 

OF LEUCORRHCEA. With numerous illustrations. In one very handsome octavo volume, 
extra cloth, of about 250 pages. $2 00 

TANNER (T. H.), M. D., 
Physician to the Hospital for Women, &c. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. 

To which is added The Code of Ethics of the American Medical Association. Third 
American Edition. In one neat volume, small 12mo., extra cloth. (Preparing.) 



TAYLOR (ALFRED S.), M . D., F. R. S. s 

Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. 

MEDICAL JURISPRUDENCE. Fifth American, from the seventh improved 

and enlarged London edition. With Notes and References to American Decisions, by Edward 

Hartshorne,M. D. In one large 8vo. volume, extra cloth, of over 700 pages. $4 00. 

This standard work having had the advantage of two revisions at the hands of the author since 
the appearance of the last American edition, will be found thoroughly revised and brought up com- 
pletely to the present state of the science. As a work of authority, it must therefore maintain its 
position, both as a text-book for the student, and a compendious treatise to which the practitioner 
can at all times refer in cases of doubt or difficulty. 

No work upon the subject can be put into the American and British legal medicine. It should be 
hands of students either of law or medicine which in the possession of every physician, as the subject 
will engage them more closely or profitably j and is one of great and increasing importance to the 
none could be offered to the busy practitioner ot public as well as to the profession.— St. Louis Med. 
either calling, for the purpose of casual or hasty and Surg. Journal. 
reference, that would be more likely tuatTord the aid 

desired We thcreforerecommend it as the best and Thia work of Dr. Taylor's is generally acknow- 
safest manuM for daily use.— American Journal of 'edged to be one of the ablest extant on the subject 
Medical Sciences of medical jurisprudence. It is certainly one of the 

Medical sciences. fh »„„,„ m , most attractive Dooks that we have met with ; sup- 

It is not excess 
before us is thei 
Jurisprudence. In saying this, we do jmt^wish^to j commenced its peru sal, few could be prevailed upon 



.. . ., . most aitractiv 

of praise to say that the volume j go , b(Hn t intere8t and instrU ct, that 

>ry best tre.at.se extant on Medical , ^ d * m)t hegitate , affirm ftat aftcr ))avj > 
n saying this, we do not wish to , conilnenced lts ,, e rusal, few could be prevailed upon 
be understood as detracting from the merits of the U) UCB1S , before completing it . In lhe lagt Lonuon 
excellent works of Beck, Ryan, Traill, Guy, and edition all the newly ob <f e rved and accurately re- 
others; but in interest and value we think it must COTded fac|g have been inserted deluding much 
be conceded that Taylor is superior to anything that that is rccent , )f chemical, Microscopical, and Pa- 
has preceded it.-N.W. Medical and Surg. Journal tho i ogical research, besides papers on numerous 
It is at once comprehensive and eminently prac- subjects never before published.— Charleston Med. 
tical, and by universal consent stands at the head of I Journal and Review. 

BY THE SAME AUTHOR. 

ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Second American, from a second and revised London edition. In one large 

octavo volume, of 755 pages, extra cloth. $5 00. 

Mr. Taylor's position as the leading medical jurist of England, has conferred on him extraordi- 
nary advantages in acquiring experience on these subjects, nearly all cases of moment being 
referred lo him for examination, as an expert whose testimony is generally accepted as final. 
The results of his labors, therefore, as gathered together in this volume, carefully weighed and- 
snted, and presented in the clear and intelligible style for which he is noted, may be received 
as an acknowledged authority, and as a guide to be followed with implicit confidence. 

BY THE SAME AUTHOR AND Witt. BRANDE. 

CHEMISTRY. In one volume fcvo. See "Rrande," p. 6. 



AND SCIENTIFIC PUBLICATIONS. 



TODD (ROBERT BENTLEY), M. D., F. R. S., 

Professor of Physiology in King's College, London; and 

WiLLIAM BOWMAN, F. R. S., 
Demonstrator of Anatomy in King's College, London. 

THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With 

about three hundred large and beautiful illustrations on wood. Complete in one large octavo 
volume, of 950 pages, extra cloth. Price $4 75. 



It is more concise than Carpenter's Principles, and 
more modern than the accessible edition of Mailer's 
Elements; its details are brief, but sufficient; its 
descriptions vivid; its illustrations exact and copi- 
ous; and its language terse and perspicuous. — 
Charleston Med. Journal. 



A magnificent contribution to British medicine, 
and the American physician who shall fail to peruse 
it, will have failed to read one of the most instruc- 
tive books of the nineteenth century.— JV. O. Med. 
and Stirg. Journal. 



TODD (R. B.) M. D., F. R. S., &c. 
CLINICAL LECTURES ON CERTAIN DISEASES OP THE URINARY 

ORGANS AND ON DROPSIES. In one oclavo volume, 284 pages, extra cloth. $2 50. 

BY THE SAME AUTHOR. 

CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat 

octavo volume, of 320 pages, extra clotn. $2 50. 



TOYNBEE (JOSEPH), F. R. S., 

Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. 

A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- 
nosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one 
very handsome octavo volume, extra cloth, $4 00. 
The work is a model of its kind, and every page Surgery, it is without a rival in ourlanguaee or any 



and paragraph o( it are worthy of the most thorough 
study. Considered all in all — as an original work, 
well written, philosophically elaborated, and happi- 
ly illustrated with cases and drawings — it is by far 
the ablest monograph that has ever appeared on the 
anatomy and diseases of the ear. and one of the most 
valuable contributions to the art and science of sur- 
gery in the nineteenth century. — JV. Amer. Medico- 
Chirurg Review, Sept. 1860. 

We are speaking within the limits of modest ac- 
knowledgment, and with a sincere and unbiassed 
judgment, when we affirm that as a treatise on Aural 



other. — Charleston Med. Journ. and Rev., Sept. 1860. 
The work of Mr. Toynbee is undoubtedly, upon 
the whole, the most valuable production of the kind 
in any language. The author has long been known 
by his numerous monographs upon subjects con- 
nected with diseases of the ear, and is now regarded 
as the highest authority on most points in his de- 
partment of science. Mr. Toynbee's work, as we 
have already said, is undoubtedly the most reliable 
guide for the study of the diseases of the ear in any 
language, and should be in the library of every phy- 
sician.— Chicago Med. Journal, July , 1860. 



WILLIAMS (C. J. B.), M.D., F. R. S., 

Professor of Clinical Medicine in University College, London, Ice. 

PRINCIPLES OF MEDICINE. An Elementaiy View of the Causes, Nature, 

Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre- 
servation of health. A new American, from the third and revised London edition. In one octavo 
volume, extra cloth, oi about 500 pages. $3 50. 

WHAT TO OBSERVE 
AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. 

Published under theauthority of the London Society for Medical Observation. A new American, 

from the second and revised London edition. In one very handsome volume, royal 12mo., extra 

cloth. $1 00. 

To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner wo 
and precision to carelessness, this little book is in- have ever seen.— Peninsular Journal of Mtditin*. 
valuable.— JV. II. Journal ofMedicin*. I 



WALSHE (W. H.) 3 M. D. t 

Professor of the Principles and Practice of Medicine in University College, London, &c. 

A PRACTICAL TREATISE ON DISEASES OF THE LUNGS; including 

the Principles of Physical Diagnosis. Third American, from the third revised and much en- 
larged Loneon edition. In one vol. octavo, of Ib'S pages extra cloth $3 00. 
The present edition has been carefully revised and much enlarged, and may be said in the main 
to be rewritten. Descriptions of several diseases, previously omitted, are now introduced; an 
effort has l>een made to bring the description <>i anatomical characters to the level of the wants oi 
the practical physician; and the diagnosis and prognosis of each complaint are? more completely 
considered The sections on Treatment and the Appendix have, especially, been largely ex- 
tended. — Author's Preface. 

BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DISEASES OF THE HEART AND 
GREAT VESSELS, including the Principles of Physical Diagnosis^ Third American, from the 
third revised and much enlarged London edition! In one handsome octavo volume of 420 pages, 
extra cloth. Sa 00. 

The present edition has been carefully revised ; much new matter has been added, and the entire 
work- in b measure remodelled. Numerous facts and discussions, more or less completely novel, 
will be found in the description of the principles of physical diagnosis; but thechiel additions have 
been made in the practical portions of the book, several affections, of which little or no account 
had been given in the previous editions, are now treated of in detail. — Author's Preface. 



30 



1-ih.XRY C. LEA'S MEDICAL 



New and much enlarged edition. 

WATSON (THOMAS), M.D., tee., 
Late Physician to the Middlesex Hospital, &c. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. 

Delivered at King's College, London. A new American, from the last revised and enlarged 

English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Treatise 

on the Diseases of Children," &c. With one hundred and eighty. five illustrations on wood. In 

one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in 

small type; extra cloth, $6 50; strongly bound in leather, with raised bands, $7 50. 

That the high reputation of this work might be fully maintained, the author has subjected it to a 

thorough revision; every portion has been examined with the aid of the most recent researches 

m pathology, and the results of modern investigations in both theoretical and practical subjects 

have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the 

editor has likewise introduced whatever possesses immediate importance to the American physician 

in relation to diseases incident to our climate which are little known in England, as well a» those 

points in which experience here has led to different modes of practice ; and he has also added largely 

to the series of illustrations, believing that in this manner valuable assistance may be conveyed to 

the student in elucidating the text. The work will, therefore, be found thoroughly on a level with 

the most advanced state of medical science on both sides of the Atlantic. 

The additions which the work has received are shown by the fact that notwithstanding an en- 
largement in the size of the page, more than two hundred additional pages have been necessary 
to accommodate the two large volumes of the London edition (which sells at ten dollars), within 
the compass of a single volume, and in its present form it contains the matter of at least three 
ordinary octavos. Believing it to be a work which should lie on the table of every physician, and 
be in the hands of every student, the publishers have put it at a price within the reach of all, making 
it one of the cheapest books as yet presented to the American profession, while at the same time 
the beauty of its mechanical execution renders it an exceedingly attractive volume. 



The fourth edition now appears, so carefully re- 
vised, as to add considerably to the value of a book 
already acknowledged, wherever the English lan- 
guage is read, to be beyond all comparison the best 
systematic work on the Principles and Practice of 
Physic in the whole range of medical literature. 
Every lecture contains proof of the extreme anxiety 
of the author to keep pace with i he advancing know- 
ledge of the day One scarcely knows whether 
to admire most the pure, simple, forcible English — 
the vast amount of useful practical infoimation 
condensed into the Lectures— or the manly, kind- 
hearted, unassuming character of the lecturer shin- 
ing through his work. — Lond. Med. Times. 

Thus these admirable volumes come before the 
profession in their fourth edition, abounding in those 
distinguished attributes of moderation, judgment, 
erudite cultivation, clearness, and eloquence, with 
which they were from the first invested, but yet 
richer than before in the results of more prolonged 
observation, and in the able appreciation of the 
latest advances in pathology and medicine by one 
of the most profound medical thinkers of the day. — 
London Lancet. 



The lecturer's skill, his wisdom, his learning, are 
equalled by the ease of his graceful diction, his elo- 
quence, and the far higher qualities of candor, of 
courtesy, of modesty, and of generous appreciation 
of merit in others.— JV. A. Med -Ckir Review. 

Watson's unrivalled, perhaps unapproachable 
work on Practice — the copious additions made to 
which (the fourth edition) have given it all the no- 
velty and much of the interest of a new book. — 
Charleston Med. Journal. 

Lecturers, practitioners, and students of medicine 
will equally hail the reappearance of the work of 
Dr. Watson in theform of a new — a fourth — edition. 
We merely do justice to our own feelings, and, we 
are sure, of the whole profession, if we thank him 
for having, in the trouble and turmoil of a large 
practice, made leisure to supply the hiatus caused 
by the exhaustion of the third edition. For Dr. 
Watson has not merely caused the lectures to be 
reprinted, but scattered through the whole work we 
find additions or alterations which prove that the 
author has in every way sought to bring up his teach- 
ing to the level of Jie most recent acquisitii 
science. — Brit, and For. Medico-Chtr." 



New and much enlarged edition. 
WILSON (ERASMUS), F. R. S. 
A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- 
vised American, from the last and enlarged English Edition. Edited by W. H.Gobrecht, M. D., 
Professor of Anatomy in the Pennsylvania Medical College, &c. Illustrated with three hundred 
and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 
large pages; extra cloth, $4 00. 

The publishers trust that the well earned reputation so long enjoyed by this work will be more 
than maintained by the present edition. Besides a very thorough revision by the author, it has been 
most carefully examined by the editor, and the efforts of both have been directed to introducing 
everything which increased experit nee in its use has suggested as desirable to render it a complete 
text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The 
amount of additions which it has thus received may be estimated from the fact that the present 
edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged 
page requisite to keep the volume within a convenient size. The editor has exercised the utmost 
caution to obtain entire accuracy in the text, and has largely increased the number of illustra- 
tions, of which there are about one hundred and fifty more in this edition than in the last, thus 
bringing distinctly before theeye of the student everything of interest or importance. 

beauty of its mechanical execution, and the clear- 



It may be recommended to the student as no less 
distinguished by its accuracy and clearness of de- 
scription than by its typographical elegance. The 
wood-cuts are exquisite. — Brit, and For. Medical 
Review . 

An elegant edition of one of the most useful and 
accurate systems of anatomical science which has 
been issued from the press The illustrations are 
really beautiful. In its style the work is extremely 
concise ami intelligible. No one can possibly take 
up this volume without being struck with the great 



ness of the descriptions which it contains is equally 
evident. Let students, by all means examine tne 
claims of this work on their notice, before they pur- 
chase a text-book of the vitally important science 
which this volume so fully and easily unfolds. — 
Lancet. 

We regard it as the best system now extant for 
students. — Western Lancet. 

It therefore receives our highestcoiumendation. — 
Southern Med. and Surg. Journal. 



AND SCIENTIFIC PUBLICATIONS. 



WILSON (ERASMUS), F. R. S. 
ON DISEASES OF THE SKIN. Fifth American, from the Fifth enlarged 



London edition. In one handsome octavo volume, of nearly 700 large 
on wood, extra cloth $4 50. 



with illustrations 



This classical work, which for twenty years has occupied the position of the leading authority 
in the English language on its important subject, has just received a thorough revision at the hands 
of the author, and is now presented as embodying the results of the latest investigations and expe- 
rience on all matters connected with diseases of the skin. The increase in the size of the work 
shows the industry of the author, and his determination that it shall maintain the position which it 
has acquired as thoroughly on a level with the most advanced condition of medical science. 

A few notices of the last edition are appended. 

The writings of Wilson, upondiseases of the skin, 
are by far the most scientific and practical that 
have ever been presented to the medical world on 
this subject. The present edition isa great improve- 
ment on all its predecessors. To dwell upon all the 
great merits and high claims of the work before us, 
seriatim, would inched be an agreeable service ; it 
would be a mental homage which we could freely 
offer, but we should thus occupy an undue amount 
of Bpace in this Journal. We will, howtver look 
at some of the more salient points with which it 
abounds, and which make iiincompuraoiy superior to 
all other treatisesonthesubjectof dermatology No 
mere speculative views are allowed a place in this 
volume, which, without a doubt will, for a very long 
period, be acknowledged as the chief standard work- 
on dermatology. The principles of an enlightened 
and rational therapeia are introduced on every ap- 
propriate occasion. — Am. Jour. Med Science. 

When the first edition of this work appeared 
about fourteen years ago, Mr Erasmus W ilson had 
already given some years to the study of Diseases 
of the Skin, and he then expressed his intention of 
devoting his future life to the elucidation of this 
branch of Medical Science In the present edition 
Mr. Wilson presents us with the results of his ma- 
tured expedience, and we have now before us not 
merely a reprint of his former publications, but an 
entirely newand rewritten volume. Thus, the whole 
history of the diseases affecting the skin, whether 
they originate in that structure or are the mere mani- 
festations of derangement of internal organs, is 
brought under noiice,and the book includes a mass 
of information which is spread over a great part of 
the domain of Medical and Surgical Pathology. We 
can Bafely recommend it to the profession as the 
best work on the subjectnow in existence in the En- 
glish language. — London Med. Times and Gazette. 



No matter what other treatises maybe in the libra- 
ry of the medical attendant, he needs the clear and 
suggestive counsels of Wilson, who is thoroughly 
posted up on all subjects connected with cutaueuus 
pathology. We have, it is very true, other valuable 
works on the maladies that invade the skin; but, 
compared with the volume under consideration, they 
are certainly to be regarded as inferior lights iu guid- 
ing the judgment of the medical man. — Boston J/eci. 
and Surg. Journal, Oct. 1S57. 

The author adopts a simple and entertaining style. 
He strives to clear away the complications of his 
subject, and has thus produced a book rilled with a 
vast amount of information, in a form so agreeable 
as to make it pleasant reading, even to the uninitiated. 
More especially does it deserve our praise because of 
its beautiful and complete atlas, which the American 
publishers have successfully imitated from the origi- 
nal plates. We pronounce them by far the best imi- 
tations of nature yet published in our country. With 
the text-book and atlas at hand, the diagnosis is ren- 
dered easy and accurate, and the practitioner feels 
himself safe in his treatment. We will add that this 
work, although it must have been very expensive to 
the publishers, is not high priced. There is no rea- 
son, then, to prevent every physician from obtaining 
a work of such importance, and one which will save 
him both labor and perplexity.— Va. Med. Journal. 

As a practical guide to the classification, diagnosis, 
and treatment of the diseases of the skin, the book is 
complete. We know nothing, considered in this as- 
pect, better iu our language; it is a safe authority on 
all the ordinary matters which, in this range of dis- 
eases, engage the practitioner's attention, and pos- 
sesses the high quality — unknown, we believe, to 
every older mauual, of being on a level with science's 
high-watermark; a sound book of practice.— London 
Mud. Times. 



A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF 

THE SKIN; consisting of twenty beautifully executed plates, of which thirteen are exquisitely 
colored, presenting the Normal Analomy and Pathology of the Skin, and containing accurate re- 
presentations of about one hundred varieties of disease, most of them the size of nature. Price 
in cloth. $5 50. 

in beauty of drawing and accuracy and finish of coloring these plates will be found equal to 
anything u/ the kind as yet issued in this country. The value of the new edition is enhanced by 
an additional Colored plate. 



The plates by which this edition is accompanied 
leave nothing to be desired, so far as excellence of 
delineation and perfect accuracy of illustration are 
concerned — Medico-C liirurgical Review. 

(ii I h BBC plates it is impossible to speak too highly. 
The representations of the. various forms of cutane- 
ous disease arc singularly accurate, aud the color- 
ing exceeds almost anything we have met with — 
British and Foreign Medical Review. 



Wc have already expressed our high appreciation 
of Mr. Wilson's treatise on Diseases of the Skit. 
The plates are comprised in a separate volume, 
which we counsel all those who possess the texl to 
purchase. It is a beautiful specimen of color print- 
ing, and the representations of the various forms of 
skin disease are us faithful as is possible in plates 
of the size.— Boston Med. and Surg. Journal, April 
8, 185B. 



Also, the TEXT aud PLATES done up in one hands >me volume, extra cloth, price $9 50. 

BY THE SAME AUTHOR. 

THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third 

American, from the lust revised and enlarged English edition. Modified and rearranged, by 
William Hunt, M. D., Demonstrator of Anatomy in the University ol Pennsylvania. In one 
larire and handsome royal l'2mo. volume, extra cloth, ol 582 pages, with 154 illustrations $2 00. 

BY THE SAME AUTHOR. 

HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- 
tion and Management. Second American, from the fourth London edition. One neat volume, 
royal 12uao., extra cloth, of about 300 pages, with numerous illustrations. $1 00. 






HENRY C. LEA'S MEDICAL PUBLICATIONS. 



WINSLOVV (FORBES), M.D., D.C.L., &c. 
ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE 



MIND; their incipient Symptoms, Pathology, 
American, from the third and revised Eugli> 
nearly 600 pages, extra cloth. §4 25. (Now 
AVe close this brief and necessarily very imperfect 
notice of Dr. Winslow's great and classical work, 
by expressing our conviction that it is long since so 
important and beautifully written a volume has is- 
sued from the British medical press.— Dublin Med. 
Press, July 25, 1660. 

We honestly believe this to be the best book of the 
season.— banking's Abstract, July, 1860. 

The latter portion of Dr. Winslow's work is ex- 
clusively devoted to the consideration of Cerebral 



Diagnosis, Treatment, and Prophylaxis. Second 
h edition. In one handsome octavo volume, ot 
Ready.) 
Pathology. It completely exhausts the subject, in 
the same manner as the previous seventeen chapters 
relating to morbid psychical phenomena left nothing 
unnoticed in reference to the mental symptoms pre- 
monitory of cerebral disease. It is impossible to 
overrate the benefits likely to result from a general 
perusal of Dr. Winslow's valuaole and deeply in- 
teresting work.— London Lancet, June 23, 1860. 

It contains an immense mass of information. — 
Brit, and For. Med.-Chir. Review, Oct. 1860. 



WEST (CHARLES), M. D., 

Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for 
Sick Children, &£. 

LECTURES ON THE DISEASES OF WOMEN. Second American, from the 

second London edition. In one handsome octavo volume, extra cloth, of about 500 pages ; 

price $3 25. 
* # * Gentlemen who received the first portion, as issued in the "Medical News and Library," can 

now complete their copies by procuring Part II, being page 309 to end, with Index, Title matter, 

&c, 8vo., cloth, price $1 25. 



We must now conclude this hastily written sketch 
with the confident assurance to our readers that the 
work will well repay perusal. The conscientious, 
painstaking, practical physician is apparent on everj 
page.— iV. Y. Journal of Medicine. 

We know of no treatise of the kind so complete 
and yet so compact. — Chicago Med. Jour. 

A fairer, more honest, more earnest, and more re- 
liable investigator of the many diseases of women 
and children is not to be found in any country.— 
Southern Med. and Surg. Journal. 

We have to say of it, briefly and decidedly, that 
it is the best work on the subject in any language ; 
and that it stamps Dr. West && the facile prmceps 
of British obstetric authors.— Edinb. Med. Journ. 



We gladly recommend his Lectures as in the high- 
est degree instructive to all who are interested in 
obstetric practice. — London Lancet. 

Happy in his simplicity of manner, and moderate 
in his expression of opinion, the author is a sound 
reasoner and a good practitioner, and his book is 
worthy of the handsome garb in which it has ap- 
peared. — Virginia Med. Journal. 

We must take leave of Dr. West's very useful 
work, with our commendaiion of the clearness of 
its style, and the incustry and sobriety of judgment 
of whicii it gives evidence.— London Med Times. 

Sound judgment and good sense pervade every 
chapter of the book. From its perusal we have de- 
rived unmixed satisfaction. — Dublin Quart. Journ. 



BY THE SAME AUTHOR. (NoiV Ready.) 

LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. 

Fourth American, from the fifth enlarged and improved London edition. In one handsome 
octavo volume, extra cloth, of about six hundred and fifty pages. $4 50. 

The numerous editions through which this work has passed on both sides of the Atlantic, are 
the best evidence that it has met a want felt by the profession. Few practitioners, indeed, have 
had the opportunities of observation and experience enjoyed by the author. In his Preface he 
remarks: "The present edition embodies the results of 1200 recorded cases, and of nearly 400 
post-mortem examinations, collected from between 30,000 and 40,01:0 children, who, during the past 
twenty-six years have come under my care, either in public or in private practice." The universal 
favor with which the work has been received shows that the author has made good use of these 
unusual advantages. 



The three former editions of the work now before 
us have placed the author in tlie foremost rank of 
those physicians who have devoted special attention 
to tlie diseases of early life We attempt no ana- 
h sis of thisedition,butmay reter the reader to some 
of the chapters to which the largest additions have 
been made— those on Diphtheria, Disorders of the 
Mind, and Idiocy, for instance— as a proot that the 
work is really a new edition; not a mere reprint. 
In its present shape, it will be lound of the greatest 
possible service in the every-day practice of nine- 
te.nths of the profession.— Med. Times and Gazette, 
London, Dec. 10, 1859. 

All things considtred. this book of Dr. West is 
by far the best treatise in our language upon such 
modifications of morbid action and diseise as are 
winntBsrd when we have to deal with infancy and 
childhood. It is true that it confines itself to such 
disorders as come within the province of the phy- 
iician, and even with respect to these it is unequal 
as Tegards mmutentss of consideration, and some 



diseases it omits to notice altogether. But those 
who know anything of the present comution of 
pcediatrics will readily admit chat it would be next 
to impossible to effect more, or effect it better, than 
the accoucheur of St. Bartholomew's has done in a 
single volume. The lecture (XVI.) upon Disorttra 
of the Mind in children is an admirable specimen of 
the value ot the later information convened in the 
Lectures of Dr. Charles West. — London Lancet, 
(Jet. 22, 1859. 

Since the appearance of the first edition, about 
eleven years ago, the experience of the author has 
doubled ; so that, whereas the lectures at first were 
founded on six hundred observations, and one hun- 
dred and eighty dissections made among nearly four- 
teen thousand children, they now embody the results 
of nine hundred observations, and two hundred and 
eighty-eight post- mortem examinations made among 
nearly thirty thousand children, who, during the 
past twenty years, have been under his care. — 
British Med. Journal, Oct. 1, 1S59. 



BY THE SAME AUTHOR. 



AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- 
ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. 



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